essay on water sanitation and hygiene

WASH – Water, Sanitation and Hygiene

The health and socio-economic benefits of safely managed water can only be fully realized alongside safely managed sanitation and good hygiene practices. Without water, sanitation and hygiene (WASH), people’s wellbeing, dignity and opportunities are severely compromised, particularly women and girls’.

Access to water and sanitation are human rights. Hygiene knowledge and facilities are life-saving, highly cost-effective health interventions. Governments must take a rights-based, integrated approach to expanding access to these vital services.

The issue explained

Billions have no access to WASH. Enormous numbers of people, the vast majority in low income countries, have no access to safely managed water and sanitation, or to handwashing facilities with soap or alcohol-based rub. Refugees and migrants often spend long periods without access.

Inadequate WASH is a major killer. Inadequate WASH devastates public health. The infectious diseases that spread through unsafe water, from improperly disposed human waste and poor hygiene practices have a profound effect on high rates of infant mortality, malnutrition and chronic illness in the general population.

Water fetching is women’s work . For many communities without safely managed water, sources are usually far from their homes, and it typically falls to women and girls to spend much of their time and energy fetching water, a task which often exposes them to abuse and attack.

Poor sanitation and hygiene endangers women and girls . Going to the toilet outside, or in facilities shared with men, puts women and girls in danger. Lack of good hygiene knowledge or facilities prevents effective menstrual hygiene management (MHM) and can lead to serious health problems.

Lack of WASH perpetuates inequality. Women, girls, older people and disabled people are precluded from full participation in public spaces, workplaces and education by inadequate or non-existent WASH facilities.

The way forward

WASH is critical to the Sustainable Development Goals (SDGs). Safely managed water and sanitation services and adequate and equitable hygiene for all will drive progress across the 2030 Agenda, particularly in health, gender equality and livelihoods.

WASH is a defence against COVID-19. Governments must address the lack of WASH in healthcare facilities to help control the spread of infectious diseases such as COVID-19, cholera and typhoid, and provide a safe environment for staff and patients.

WASH must be central to climate adaptation plans . Governments must ensure that water and sanitation services and hygiene behaviours and facilities can withstand and be sustained during and after climate-related disasters, helping to protect public health in an uncertain future.

WASH can drive economic growth. Investment in WASH generates positive returns in reduced medical burden and increased productivity, removes barriers to marginalized groups’ participation in society, and creates long-term jobs.

Facts and Figures

• 2.2 billion still live without safely managed drinking water, including 115 million people who drink surface water. ( WHO/UNICEF, 2023 )  
• 3.5 billion people still live without safely managed sanitation, including 419 million who practise open defecation. ( WHO/UNICEF, 2023 )  
• Unsafe water, sanitation and hygiene are responsible for the deaths of around 1,000 children under 5 every day. ( WHO, 2023 )  
• 2 billion still lack basic hygiene services, including 653 million with no facility at all. ( WHO/UNICEF, 2023 )  
• The 1.9 billion people living in fragile contexts are twice as likely to lack safely managed drinking water and basic hygiene and 1.5 times as likely to lack safely managed sanitation services. ( WHO/UNICEF, 2023 )  
• To achieve SDG 6 – water and sanitation for all by 2030 – will require a six-fold increase in current global rates of progress on drinking water, a five-fold increase for sanitation, and a three-fold increase for hygiene. ( UN-Water, 2023 )  
• At the current rates of progress, 3 billion people will still be living without safe toilets, 2 billion without safe drinking water, and 1.4 billion without basic hygiene services in 2030. ( WHO/UNICEF, 2023 )  
• Almost half of the schools in the world do not have handwashing facilities with soap and water. ( WHO/UNICEF, 2020 )  
• Approximately 50 litres of water per person per day are needed to ensure that most basic needs are met while keeping public health risks at a low level. ( WHO, 2017 )  
• 207 million people spend over 30 minutes per round trip to collect water from an improved source. ( WHO/UNICEF, 2019 )  
• Globally, at least 2 billion people use a drinking water source contaminated with faeces. ( WHO, 2019 )  
• Under-fives living in countries experiencing protracted conflict are 20 times more likely to die from causes linked to unsafe water and sanitation than from direct violence. ( UNICEF, 2019 )  
• 1 million deaths each year are associated with unclean births. Infections account for 26% of neonatal deaths and 11% of maternal mortality.  (WHO/UNICEF, 2019)  
• Hygiene promotion is the most cost-effective health intervention. ( World Bank, 2016 )  
• Loss of productivity to water- and sanitation-related diseases costs many countries up to 5% of GDP. ( WHO, 2012 )  
• Universal access to safe drinking water and adequate sanitation and hygiene would reduce the global disease burden by 10%. ( WHO, 2012 )  
• Urban basic drinking water: $3 return for every $1 invested.
• Urban basic sanitation: $2.5 to $1
• Rural basic drinking water: $7 to $1
• Rural basic sanitation: $5 to $1

Essay on Water Sanitation And Hygiene

Students are often asked to write an essay on Water Sanitation And Hygiene in their schools and colleges. And if you’re also looking for the same, we have created 100-word, 250-word, and 500-word essays on the topic.

Let’s take a look…

100 Words Essay on Water Sanitation And Hygiene

What is water sanitation and hygiene.

Water Sanitation and Hygiene, often called WASH, is about keeping water clean, getting rid of waste safely, and keeping hands and bodies clean. These are important for staying healthy, stopping diseases, and living a better life. Clean water is needed for drinking, cooking, and cleaning.

Why is Clean Water Important?

Clean water keeps us from getting sick. Drinking or using dirty water can cause diseases like cholera. That’s why it’s important to have clean water for everyone.

Keeping Our Surroundings Clean

Getting rid of waste the right way stops germs from spreading. Toilets and proper waste systems help keep our environment clean and safe.

Handwashing: A Simple Step

Washing hands with soap is a simple way to stop germs. Doing this before eating or after using the toilet can prevent illnesses. It’s an easy habit with big health benefits.

Working Together

250 words essay on water sanitation and hygiene, importance of water sanitation and hygiene.

Clean water, proper sanitation, and good hygiene practices are essential for maintaining good health and preventing the spread of diseases. Access to clean water and sanitation is a fundamental human right, and everyone should have access to these basic necessities. Poor sanitation and hygiene practices can contribute to the transmission of diseases, such as diarrhea, cholera, typhoid, and dysentery. These diseases can cause severe illness and even death, and they disproportionately affect vulnerable populations, such as children and the elderly.

Access to Clean Water

Access to clean water is essential for drinking, cooking, cleaning, and sanitation. When people do not have access to clean water, they are often forced to rely on unsafe sources of water, such as contaminated wells, rivers, or lakes. This can lead to waterborne diseases, which can cause a variety of health problems. In addition, lack of access to clean water can make it difficult to maintain good hygiene practices, which can also contribute to the spread of disease.

Sanitation and Hygiene

Sanitation and hygiene practices are also essential for preventing the spread of disease. Proper sanitation includes the safe disposal of human waste and wastewater, as well as the provision of clean and hygienic latrines. Good hygiene practices include washing hands with soap and water, brushing teeth, and bathing regularly. These practices help to remove germs and bacteria from the body and prevent the spread of infection.

Water sanitation and hygiene are essential for maintaining good health and preventing the spread of disease. Access to clean water, sanitation, and good hygiene practices are fundamental human rights, and everyone should have access to these basic necessities. By working together, we can ensure that everyone has the opportunity to live a healthy and productive life.

500 Words Essay on Water Sanitation And Hygiene

Water sanitation and hygiene: staying healthy and happy.

Water, sanitation, and hygiene (WASH) are essential for human health and well-being. WASH refers to the availability of clean water, proper sanitation facilities, and good hygiene practices. These elements work together to prevent diseases, promote good health, and improve overall quality of life.

Clean Water: The Foundation of Good Health

Sanitation: keeping our surroundings clean.

Sanitation refers to the proper disposal of human waste and wastewater. Adequate sanitation facilities, such as toilets and latrines, help prevent the spread of diseases and ensure a clean and healthy environment. Poor sanitation, on the other hand, can contaminate water sources, attract disease-carrying insects, and create unpleasant odors.

Hygiene: Personal Cleanliness and Healthy Habits

Hygiene refers to personal cleanliness and healthy habits that help prevent the spread of germs and infections. Handwashing with soap and water is one of the most important hygiene practices, as it helps remove germs from our hands and prevents them from spreading to others or our food. Other important hygiene practices include taking regular baths, brushing our teeth, and covering our mouths when we cough or sneeze.

WASH in Schools: Promoting Healthy Learning Environments

Conclusion: investing in wash for a healthier future.

Investing in WASH is an investment in the health and well-being of individuals and communities. By providing access to clean water, sanitation facilities, and promoting good hygiene practices, we can prevent diseases, improve health, and create a better quality of life for everyone. WASH is a cornerstone of public health and a fundamental human right that should be available to all.

That’s it! I hope the essay helped you.

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Water, Sanitation and Hygiene, or WASH, are issues that affect the health and wellbeing of every person in the world. Everyone needs clean water to drink. Everyone needs a safe place to pee and poop. And everyone needs to be able to clean themselves. For many people, WASH concerns are taken for granted and their combined impact on life isn’t always appreciated.

But for hundreds of millions of others, water, sanitation and hygiene are constant sources of stress and illness. The quality of water, sanitation and hygiene in a person’s life is directly correlated to poverty, as it is usually joined by lack of education, lack of opportunity and gender inequality.  

What’s the scope of the problem?

780 million people do not have regular access to clean water.

2.4 billion people, or 35% of the global population, do not have access to adequate sanitation.

A local resident washes in an Indian slum colony in New Delhi Image: Flickr: Gates Foundation

Inadequate sanitation generally means open defecation. When people defecate in the open without a proper waste management system, then the feces generally seeps into and contaminates water systems. Just standing in an open defecation zone can lead to disease, if, for instance, the person is barefoot and parasites are there.

The problem is concentrated in Sub-Saharan Africa, Southern Asia and Eastern Asia. The country with the most people lacking adequate WASH is India.

Girls are the hardest hit by lack of clean water and sanitation for a few reasons. When schools lack functional toilets or latrines, girls often drop out because of the stigma associated with periods. Also, when families don’t have enough water, girls are generally forced to travel hours to gather some, leaving little time for school. This lack of education then contributes to higher poverty rates for women.

What are the health risks?

There are a lot of health risks associated with inadequate WASH. Just imagine what it would be like if you were drinking contaminated water and everyone in your community defecated in the open.

801,000 kids under the age of 5 die each year because of diarrhea. 88% of these cases are traced to contaminated water and lack of sanitation.

More than a billion people are infected by parasites from contaminated water or open defecation. One of these parasites is called the Guinea Worm Disease, which consists of worms up to 1 meter in size that emerge from the body through blisters.

Image: Flickr - Andrew Moore

The bacterial infection Trachoma generally comes from contaminated water and is a leading cause of blindness in the world.

Other common WASH-related diseases include Cholera, Typhoid and Dysentery.

And, again, step back to consider what life without clean water and adequate sanitation would be like. A lot of your time would be spent trying to get clean water and avoid sanitation problems in the first place. And the hours not revolving around these concerns would probably be reduced quality of life because of the many minor health problems associated with poor water quality. Ultimately, inadequate WASH leads to reduced quality of life all the time.

What’s being done?

For every $1 USD invested in WASH programs, economies gain $5 to $46 USD. In the US, for instance, water infrastructure investments had a 23 to 1 return rate in the 20th century. When people aren’t always getting sick, they’re more productive and everyone benefits.

While the numbers are daunting, a lot is being done. And the economic benefits of WASH investments make the likelihood of future investments and future progress much higher.

Some investments are small-scale, others are large-scale. On the smaller side of the spectrum, investments can go toward water purification methods, community wells or sources of water and the construction of community latrines.

Image: Michael Sheldrick

For instance, in a slum in Nairobi, Kenya, the government recently installed ATM-style water dispensers that provide clean water to the whole community.

Larger scale investments include piped household water connections and household toilets with adequate sewage systems or septic tanks.

An often overlooked aspect of WASH involves behavioral hygiene, and, more specifically, hand washing. Simply washing your hands with soap can reduce the risk of various diseases, including the number 1 killer of the world’s poorest children: pneumonia .

What progress has been made?

In 1990, 76% of the global population had access to safe drinking water and 54% had access to adequate sanitation facilities.

In 2015, even though the population had climbed by more than 2 billion people, 91% of people had access to safe drinking water and 68% had access to improved sanitation.

That means in 25 years, 2.6 billion people gained access to safe drinking water and 2.1 billion gained access to improved sanitation.

India is currently in the process of an unprecedented WASH investment program. At the 2014 Global Citizen Festival, Prime Minister Narendra Modi committed to end open defecation in the country and has since mobilized substantial resources with the help of The World Bank .

What role does Global Citizen play in all this?

Global Citizen puts pressure on world leaders to focus on and direct money to poverty solutions around the world. When it comes to WASH, global citizens have helped raise awareness of the various associated problems and motivate politicians to invest in specific programs.

Head over to our Impact page to read more about specific achievements. 

Defeat Poverty

Why Clean Water, Sanitation And Hygiene Are So Important

Aug. 23, 2016

ENCYCLOPEDIC ENTRY

Sustainable development goal 6: clean water and sanitation.

The Sustainable Development Goals were adopted by the United Nations in 2015 to work toward a sustainable and poverty-free world by 2030. Goal 6, in particular, seeks to ensure that people have access to clean water and adequate sanitation services worldwide.

Biology, Health, Conservation

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The members of the United Nations (UN) adopted the Sustainable Development Goals (SDGs) in 2015. These 17 goals are designed to unite nations in the common cause of ensuring the general welfare of all humans by the year 2030. These goals include a focus on ending poverty, tackling climate change , and maintaining high standards of resources.

SDG 6 focuses on ensuring a clean and stable water supply and effective water sanitation for all people by the year 2030. The goal is a reaction to the fact that many people throughout the world lack these basic services. About 40 percent of the world’s population is affected by a lack of water. As global temperatures rise, that total is expected to increase. Already, some of the poorest countries in the world are affected by drought , resulting in famine and malnutrition . Throughout the world, about 1.7 billion people live in a watershed where water is used faster than the watershed can be replenished. According to some estimates, if such trends continue, one in four people, or more, might experience water shortages on a regular basis by the year 2050.

Compounding the problem of water scarcity is the lack of reliable sanitation throughout the world. More than two billion people worldwide lack basic sanitation services, such as simple latrines or toilets. More than 890 million of those people live in regions where “open defecation” occurs. This means that human waste is left in the open. Adding to the issue is the fact that 80 percent of wastewater throughout the planet is emptied into the ocean or rivers without proper waste removal.

Alarmed by these problems, the UN established SDG 6 in an effort to make adequate sanitation and water services available to all people by the year 2030. As many as 800 million people, or more, would require the construction of facilities to provide consistent clean water and waste removal. To succeed in their vision, the UN developed a series of targets. These targets include restoring and protecting river ecosystems throughout the world, eliminating sources of water pollution , and increasing international cooperation to bring services throughout the world.

In an effort to reach the targets outlined by SDG 6, some water companies have installed smart meters in places where water scarcity is a concern. These meters track and charge for every drop of water used in a household, which has led to higher water conservation in countries like The Gambia and Tanzania. The CEO of one such company, eWATERpay, claims that these meters have reduced water waste by 99 percent.

Such efforts take time and require many countries to work together. While some strides have been made, based on information from a 2017 UN study, not enough has been done to ensure that this goal will be met by 2030. Managing these targets properly is the only way to make certain all people will benefit from clean water and effective sanitation in the years ahead.

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Related Resources

Tapping the Benefits of Clean Water, Sanitation, and Hygiene

By Guest Blogger on July 6, 2017

By Katie Dahlstrom, Nestlé Corporate Communications Manager and Helen Medina, Nestlé Senior Public Affairs Manager, Government and Multilateral Relations

Clean water is one of the few things in life that never fails to live up to expectations.

It is difficult to overstate the importance of having it. In fact, it’s probably impossible. Clean water changes almost everything. This is also why access to and management of clean water, sanitation, and hygiene are included in the Sustainable Development Goals (SDGs), specifically, SDG 6, which Nestlé is contributing directly through our partnership with the International Federation of Red Cross and Red Crescent Societies (IFRC). But how are we doing this?

Tapping the benefits

Having clean water and sanitation means being able to avoid exposure to countless diseases.

Every year, millions of people die from diseases caused by inadequate water supply, sanitation, and hygiene. Other than pneumonia, diarrhea is the  main cause of death  in children under age 5.

Poor sanitation and unsafe water  cause nearly 20% of workplace deaths . It costs around  $260 billion  in lost productivity every year.

But the benefits of having a source of clean water in a community are much wider. When women and girls no longer have to walk miles to fetch water each day, they have more time to learn. Literacy rates rise. And when schools build proper toilet facilities,  girls spend more time in school and less time at home.  

The  United  N ations  estimates that every Swiss franc invested in water and sanitation leads to four francs in economic returns – which is why investing in this area is such an effective way of creating stronger, more resilient communities.

Connecting communities

In Côte d’Ivoire,  63% of the population lacks access to proper sanitation . People must often walk miles to collect water, which may not even be safe to drink, as well as use open air, unhygienic shared toilets.  

The IFRC is working across Côte d’Ivoire to extend access to clean water, sanitation, and hygiene.

As the IFRC’s longest-standing corporate partner, Nestlé has helped to deliver clean water and sanitation to almost 110,000 people in Côte d’Ivoire’s cocoa-growing communities for the past 10 years.  

A total of 181 water pumps and 93 blocks of school toilets have been built or renovated as well as more than 7,000 family latrines.  

Education has been an essential part of the effort too. More than 200 community water and sanitation committees and 93 school hygiene clubs have been established since 2007.  

Their members promote hygiene in their local area. They teach people how to store water safely and build safe sanitation facilities, and children how to wash their hands well. Sometimes it is the simplest measures that have the biggest effect.  

“Our grandchildren will not suffer…”

Adjoua is a 55-year-old widow from the village of Ndri Koffikro in the south of Côte d’Ivoire. She recalls that ever since she was young, her community’s biggest wish has been to have access to safe drinking water. Traditionally, residents relied on ponds and a river nestled in a forest two kilometers away for their water.

Before the IFRC committed to building a water point in the village, it made sure a viable management system could be set up with community members. A management committee, which consists of six women and two men from the village, oversees the operation and maintenance of the water point and handles the accounts related to the income generated from selling water.

It ensures that the investment made in the water point will live on for generations.  

“Now, I and my community members will have more time and energy to take care of our family as well as our farming activities,” says Adjoua. “Our grandchildren will not suffer all the pains we went through.”

Safe water and better hygiene reduce the burden of ill health on families and allow women more time to earn their own income. An end to open defecation means people are safer – particularly at night – and the land is cleaner and the crops healthier.  

Meaningful progress

Education programs teach school children good hygiene habits. Some  768 million people still do not have access to an improved source of drinking water ; 40% of them in sub-Saharan Africa. There is still a long way to go, but progress is being made.

With the program up and running successfully in Côte d’Ivoire, the next phase of the project has already begun in Ghana, where wells are now being constructed. Over 76,000 people in cocoa producing communities that Nestlé works with will have better access to clean water and sanitation by April 2018.  

By bringing basic hygiene knowledge alongside clean water, the IFRC program ensures that the health benefits of its work endure.  

[Photo: Copyright Nestlé S.A. and by Remo Naegli]         

This post is part of the “SDG Solutions” series hosted by the United Nations Foundation, Global Daily, and +SocialGood to raise awareness of ways the international community can advance, and is advancing, progress on the Sustainable Development Goals. As the international community prepares to gather at the UN for the High-Level Political Forum on Sustainable Development from July 10-19, this series will share ideas and examples of action. Previous posts in the series can be found here .

Nestlé   is a part of the Every Woman Every Child movement, launched in 2010 and led by the UN Secretary-General, to intensify commitment and action by governments, the UN, multilaterals, the private sector, and civil society to keep women’s, children’s and adolescents’ health and wellbeing at the heart of development. As a multi-stakeholder platform to operationalize the Every Woman Every Child Global Strategy for Women’s, Children’s and Adolescents’ Health, the movement mobilizes partnerships and coordinated efforts across sectors to ensure that all women, children and adolescents not only survive, but also thrive to help transform the world. Learn more : http://www.everywomaneverychild.org/

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Chapter 9 water supply, sanitation, and hygiene.

Guy Hutton and Claire Chase .

• Introduction

Safe drinking water, sanitation, and hygiene (WASH) are fundamental to improving standards of living for people. The improved standards made possible by WASH include, among others, better physical health, protection of the environment, better educational outcomes, convenience time savings, assurance of lives lived with dignity, and equal treatment for both men and women. Poor and vulnerable populations have lower access to improved WASH services and have poorer associated behaviors. Improved WASH is therefore central to reducing poverty, promoting equality, and supporting socioeconomic development. Drinking water and sanitation were targets in the Millennium Development Goals (MDGs) for 2015; under the Sustainable Development Goals (SDGs) for the post-2015 period, Member States of the United Nations (UN) aspire to achieve universal access to WASH by 2030. The Human Right to Safe Drinking Water and Sanitation (HRTWS) was adopted in 2010 under a UN resolution calling for safe, affordable, acceptable, available, and accessible drinking water and sanitation services for all. 1

The scope of WASH services included in this chapter is shown in table 9.1 . The focus is on services at the household and institutional level and on services for personal rather than productive uses.

Scope of Water, Sanitation, and Hygiene Services Included in This Chapter.

This chapter summarizes global evidence on current WASH coverage and effects of intervention options, and it recommends areas for research and policy. Evidence comes from published synthesized evidence, such as systematic reviews and meta-analyses, evidence papers, and literature reviews. When those sources were not available, evidence was compiled from the next best sources of published research, thus using accepted criteria of the hierarchy of evidence for studies on health effectiveness. Unpublished and grey literature was used where no peer-reviewed published evidence exists.

This chapter is structured as follows:

• Progress in improving drinking water, sanitation, and hygiene coverage
• Impacts of poor WASH, thereby summarizing the evidence on the continued decline in mortality from diarrheal disease and the emerging evidence on the long-term developmental and cognitive effects of inadequate WASH on children
• Effectiveness of interventions, thereby examining the health effects of specific WASH interventions, the approaches to service delivery, and the key role of broader institutional policy in accelerating and sustaining progress
• Intervention costs, efficiency, and sustainability, thereby assessing the socioeconomic returns of improved WASH and considering the requirements for populations to have continued access to WASH services
• Challenges, opportunities, and recommendations.

This chapter uses the World Health Organization (WHO) classification of superregions as follows: Africa, the Americas, South-East Asia, Europe, Eastern Mediterranean, and Western Pacific.

• Status of Drinking Water, Sanitation, and Hygiene

The MDG targets called for halving the proportion of the population without sustainable access to safe drinking water and basic sanitation between 1990 and 2015. The targets were ambitious. In 1990, 76 percent of the global population used an improved drinking water source, and 54 percent had access to safe sanitation. The MDG’s drinking water target was met in 2010; yet in 2015, the world remained 9 percentage points short of achieving the sanitation target. The SDGs for 2015–2030 have broadened from the MDG period to include (1) water-use efficiency across all sectors, sustainable withdrawals, and supply of freshwater to people suffering from water scarcity; (2) integrated water resource management, and (3) water-related ecosystems. The SDG also set ambitious WASH-related targets of universal access to safe water (target 6.1), adequate sanitation and hygiene, and the elimination of open defecation (target 6.2) as well as reduced untreated wastewater (target 6.3). In the overall aim of access for all, the SDG language and spirit emphasizes progressive reduction of inequalities and leaving no one behind, as well as providing inclusive, quality, and sustainable services—thereby ensuring access for women and for poor and vulnerable populations.

• Definitions

To understand the status of drinking water, sanitation, and hygiene, one must make a distinction between different levels of service access and population practices. All populations meet water and sanitation needs in some way, but those ways are often not sufficient, reliable, safe, convenient, affordable, or dignified. To monitor the MDG water and sanitation target, the UN distinguished between improved and unimproved water and sanitation facilities at home. For the SDG targets, one indicator is proposed per target: (1) for target 6.1, the percentage of population using safely managed drinking water services and (2) for target 6.2, the percentage of population using safely managed sanitation services, including a handwashing facility with soap and water. Complementing these proposals is a broader set of indicators distinguishing basic and safely managed service levels ( table 9.2 ) ( WHO and UNICEF 2015a ).

Proposed Service Level Definitions for Monitoring SDG 6 WASH Targets.

The indicators for global monitoring need to be kept simple for feasibility and cost. However, countries, organizations, and programs often monitor different aspects of service performance, such as quantity, quality, proximity, reliability, price, and affordability ( Roaf, Khalfan, and Langford 2005 ). Some countries adopt more lenient definitions, and some adopt stricter definitions.

The definitions in existing monitoring systems have several limitations. Some limitations are partially addressed by the new indicators for higher-level services. The new indicators were informed by the five normative criteria, as stated in the HRTWS and shown in table 9.2 : accessibility, acceptability, availability, affordability, and quality. 2

• The Joint Monitoring Programme’s (JMP) definition of improved facilities focuses on the technology type and is an imprecise proxy for the quality of services ( Moriarty and others 2010 ; Onda, LoBuglio, and Bartram 2012 ; Potter and others 2010 ).
• Self-reported responses of access by household members may be biased ( Stanton and Clemens 1987 ).
• Statistics on household access provide no indication of variations in access and practices among different household members. For example, even in communities with high coverage rates for sanitation, children still commonly defecate in the open. 3
• Indicators do not adequately reflect accountability and sustainability, which are key elements that cut across all the service levels.

The existing approach to measuring access does not provide a good indication of sustainability. The surveys use representative sampling and do not follow individual households over time. Effective monitoring of higher service levels requires regulatory data, but coverage is poor in low- and middle-income countries (LMICs), especially in rural areas.

• Coverage of Water Supply, Sanitation, and Hygiene

This section presents the coverage data at global and regional levels for drinking water and sanitation according to the JMP definitions used for monitoring MDG target 7c, thereby using the most recent update and MDG assessment report ( WHO and UNICEF 2015b ). Breakdowns are provided by rural and urban areas. 4

• Water Supply

Globally, the use of improved drinking water sources increased from 76 percent in 1990 to 91 percent in 2015 ( WHO and UNICEF 2015b ). Regional breakdowns for progress between 1990 and 2015 are shown in figure 9.1 . In its 2012 report presenting 2010 estimates, the UN showed that its MDG target of halving the proportion of the population without access to safe drinking water had been met ( WHO and UNICEF 2012b ); however, such global estimates mask regional disparities and inequities in access between urban and rural populations. As of 2015, 663 million people still used unimproved water sources, compared to 1.3 billion in 1990; 2.6 billion people have gained access to improved water since 1990. Rural dwellers remain unserved compared with urban dwellers (16 percent and 4 percent, respectively). In Sub-Saharan Africa, 44 percent of rural dwellers continue to use an unimproved water supply. Water hauling costs Sub-Saharan Africans, especially women, billions of hours each year. In 2008, more than 25 percent of the population in several Sub-Saharan African countries spent more than 30 minutes to make one round trip to collect water; 72 percent of the burden for collecting water fell on women (64 percent) and girls (8 percent), compared with men (24 percent) and boys (4 percent) ( WHO and UNICEF 2010 ).

Drinking Water Coverage Trends, by Regions and World, Using the JMP Improved Water Definition, 1990–2015.

Urban areas enjoy a higher level of water service, as indicated by the use of piped water supply; in 2015, four of five people living in urban areas used piped water, compared to two of three in rural areas. Water sources classified as improved—even piped water—do not guarantee the safety or continuity of the water supply. Water quality surveys conducted in five countries showed that microbiological compliance with the WHO guidelines varied between water sources and countries ( Onda, LoBuglio, and Bartram 2012 ). On average, compliance was close to 90 percent for piped water sources, and from 40 percent to 70 percent for other improved sources. Extrapolating to global estimates, the authors estimate that in 2010, 1.8 billion people (28 percent) used unsafe water, more than twice the population of 783 million (11 percent) that used an unimproved water supply.

The use of improved sanitation increased from 54 percent in 1990 to 68 percent in 2015, but those gains fell short of meeting the global MDG target ( WHO and UNICEF 2015b ). In 2015, 2.4 billion people still did not have access to their own improved sanitation facility, a fact that, due to population growth, reflects no change in the unserved population of 1990. However, these numbers mask the fact that since 1990, 2.1 billion people have gained access to improved sanitation. Regional breakdowns in progress between 1990 and 2015 are shown in figure 9.2 . Globally, the proportion of population practicing open defecation declined from 24 percent in 1990 to 13 percent in 2015. In South Asia, 34 percent still defecate in the open, compared to 23 percent in Sub-Saharan Africa. Globally, 638 million people (9 percent) share their sanitation facility with another family or families. Comparing rural and urban areas, 51 percent of rural dwellers have access to improved sanitation, compared with 82 percent of urban dwellers. Rates of improved sanitation do not reflect the amount of fecal waste that is not isolated, transported, or treated safely; a study of 12 cities in LMICs found that whereas 98 percent of households used toilets, only 29 percent of fecal waste was safely managed ( Blackett, Hawkins, and Heymans 2014 ).

Sanitation Coverage Trends, by Regions and World, Using the JMP Improved Sanitation Definition, 1990–2015.

Although the MDG target 7c does not provide a global indicator for hygiene, the data on the presence of a handwashing facility with soap and water are increasingly collected as part of nationally representative surveys and will form the basis for efforts to monitor target 6.2 of the SDGs. Two main sources include nationally representative household surveys and a global review of published studies ( Freeman and others 2014 ). Research studies suggest that the global prevalence of handwashing with soap after contact with excreta is 19 percent; rates are lower in Sub-Saharan Africa (14 percent) and South-East Asia (17 percent), where the most studies have been conducted ( Freeman and others 2014 ). Proxy indicators for handwashing practice from nationally representative surveys are not reliable and tend to over report hygiene practices ( Biran and others 2008 ).

• Distribution of Services

The JMP has reported the distribution of water supply and sanitation services by wealth status, breaking the population into five equal wealth quintiles using an asset index. In 35 Sub-Saharan African countries, households in the poorest wealth quintile are 6 times less likely to have water access compared with the richest quintile; the difference for sanitation is at least 2.5 times less likely ( WHO and UNICEF 2013 ). Figure 9.3 illustrates the levels of disparity—between regions, between countries in a region, and at the country level—in the differences between rural and urban areas and between wealth quintiles. Limited datasets are available on the disparities between population subgroups—for example, slum populations, ethnic groups, women, the elderly, and persons who have physical impairments—as the sample size and sampling methodology in nationally representative surveys generally do not enable sufficiently robust comparisons.

Mozambique Example: How Average Values Mask Massive Disparities in Household Coverage.

Global reporting of institutional WASH has not yet been standardized as it has for household-level WASH; efforts are under way to build a global reporting system of WASH in schools and health facilities for SDG monitoring. The Demographic and Health Survey (DHS) Service Provision Assessment (SPA) monitors WASH in health facilities. WASH coverage in both primary schools and front-line health facilities is monitored and reported under the Service Delivery Indicators, currently for Sub-Saharan Africa. United Nations agencies collect data on WASH in schools (Education Management Information System operated by UNICEF), health facilities (Health Management Information System operated by the WHO), and refugee camps (UN High Commissioner for Refugees).

In addition to enhanced monitoring efforts by UN agencies, UN member countries need greater understanding of the challenges facing the world to meet the goal of universal access to institutional WASH within 15 years and to sustain that access beyond 2030. Unsustainable water extraction, along with competing demands, population growth and migration (including urbanization), and climate change and variability, puts significant pressure on water supply systems. In addition, new settlements require systematic, coordinated planning, and existing settlements require retrofitting to bring sustainable WASH services to citizens.

• Impacts of Inadequate Wash

Understanding the nature and extent of the demonstrated negative effects of inadequate WASH on individuals, the environment, and societies is important for those designing interventions and assessing benefits and efficiency. Many benefits of WASH interventions are nonhealth in nature; including only health effects in impact evaluations can severely underestimate the intervention benefits ( Loevensohn and others 2015 ).

• Health Consequences

Contaminated water and lack of sanitation lead to the transmission of pathogens through feces and, to a lesser extent, urine. The F-diagram explained here but not shown provides a basic understanding of these pathways by which pathogens from feces are ingested through transmission by fingers, flies, fluids, fields (soil), and food:

• Diseases transmitted by the fecal pathway include diarrheal disease, enteric infection, hepatitis A and E, poliomyelitis, helminths, trachoma, and adenoviruses (conjunctivitis) ( Strickland 2000 ). Most of these diseases are transmitted through the fecal-oral pathway, but some are transmitted through the fecal-skin pathway (for example, schistosomiasis) and the fecal-eye pathway (for example, trachoma). These transmissions occur between humans, as well as between animals and humans.
• Pathogens carried through urine (for example, leptospirosis) mainly result from animal-to-human transmission.
• Poor personal hygiene causes fungal skin infections, such as ringworm (tinea) and scabies.
• Lack of handwashing is associated with respiratory infections ( Rabie and Curtis 2006 ); inadequate hand hygiene during childbirth is linked to infection ( Semmelweis 1983 ) and neonatal mortality ( Blencowe and others 2011 ; Rhee and others 2008 ).

A systematic review and meta-analysis documented large and significant associations between poor water, sanitation, and maternal mortality ( Benova, Cumming, and Campbell 2014 ). The precise mechanism has not been well established, but it is thought to be largely attributable to puerperal sepsis.

Children under age five years are especially vulnerable to infection. Regular exposure to environments with high fecal loads causes enteropathy 5 ; compromises nutritional status; and leads to long-term consequences, such as stunting and retarded cognitive development ( Humphrey 2009 ; Petri and others 2008 ).

The availability of water for drinking and household uses affects the quantity of water consumed and the time available to care for children in the household. Reducing the distance required to fetch water is associated with lower prevalence of diarrhea, improved nutrition, and lower mortality in children under age five years ( Pickering and Davis 2012 ); these effects may be due to better hygiene practices ( Curtis and Cairncross 2003 ; Esrey 1996 ; Esrey and others 1991 ), as well as to additional time available for child care or income-generating activities ( Ilahi and Grimard 2000 ), thereby resulting in healthier children.

Inadequate quantities or consumption of water can also lead to dehydration, which has a number of adverse effects on physical and cognitive performance and bodily functions ( Popkin, D’Anci, and Rosenberg 2010 ). Because there are no adequate biomarkers for measuring a population’s hydration status, such an effect remains largely undocumented ( Popkin, D’Anci, and Rosenberg 2010 ). Safe drinking water provides the basis for oral rehydration salts that save lives ( Atia and Buchman 2009 ).

Exposure to harmful levels of arsenic in groundwater is estimated to affect 226 million people in more than 100 countries ( Murcott 2012 ). Arsenic exposure causes skin lesions and long-term illnesses such as cancer, neurological disorders, cardiovascular diseases, diabetes, and cognitive deficits among children ( Naujokas and others 2013 ).

Excess levels of water from heavy rainfall and inadequate drainage lead to flooding, thus causing injuries and death, as well as heightened risk of fecal-oral and skin diseases ( Ahern and others 2005 ). Earthquakes, volcanic eruptions, tsunamis, and other natural disasters leave affected populations vulnerable to infection with waterborne diseases such as diarrhea, hepatitis A and E, and leptospirosis ( Jafari and others 2011 ).

• Diarrheal Disease

The most recent study estimated 842,000 global deaths from diarrheal disease for 2012 ( Prüss-Ustün and others 2014 ); 43 percent of these were children under age five years. An estimated 502,000 deaths were caused by inadequate drinking water, 280,000 by inadequate sanitation, and 297,000 by inadequate hand hygiene ( table 9.3 ). The regional breakdowns indicate that the major share of global burden is in South-East Asia and Sub-Saharan Africa. Precise estimates remain elusive because of poor quality data on the cause of death; insufficient data on hygiene practices; and poor quality evidence on the effectiveness of some water and sanitation interventions, especially onsite sanitation. This paucity of reliable data has led to conflicting estimates of the burden of disease. The Institute for Health Metrics and Evaluation’s Global Burden of Disease (GBD) study conducted a new meta-regression analysis of available experimental and quasi-experimental interventions. It found that poor water and sanitation account for 0.9 percent of global disability-adjusted life years (DALY) or 300,000 deaths per year ( Lim and others 2012 ). The resulting difference between this study and the Prüss-Ustün and others (2014) study is 542,000 deaths, possibly because the studies included in the GBD study do not differentiate between different levels of quality of water supply and sanitation and between poor quality implementation and lack of effect.

Diarrheal Disease Mortality Attributed to Poor Water Supply, Sanitation, and Hygiene in Low-and Middle-Income Countries, Regional and Risk Factor Breakdown.

Not all diarrheal diseases are caused by pathogens transmitted through inadequate WASH. Over time, different estimates have been made for the burden of diarrheal disease that can be attributed to fecal-oral transmission. Earlier estimates attribute 94 percent of diarrheal disease to poor WASH ( Prüss-Ustün and Corvalan 2007 ); the more recent study attributes 58 percent ( Prüss-Ustün and others 2014 ). This latter estimate is closely supported by a separate review of more than 200 studies that examined the causes of diarrhea in inpatients and found no pathogen present in 34 percent of cases ( Lanata and others 2013 ). Importantly, deaths not easily preventable through WASH interventions (for example, rotavirus spread among young children and difficult to control) were excluded from the global burden of disease estimates for diarrheal disease shown in table 9.3 . Thus, the data in table 9.3 provide a more realistic picture on how many deaths are considered preventable by WASH interventions.

Rising temperatures caused by climate change are expected to exacerbate the burden of diarrheal disease. The WHO estimates that an additional 48,000 deaths in children under age 15 years will be caused by climate change by 2030 and 33,000 deaths by 2050 ( Hales and others 2014 ). These estimates may be conservative because they do not account for diarrheal deaths caused by other risk factors such as declining water availability and undernutrition.

Cholera is an endemic diarrheal disease, but it is strongly associated with natural disasters and civil conflict. An estimated 2.9 million cases of cholera cause 95,000 deaths each year in 69 endemic countries ( Ali and others 2015 ). Cholera is transmitted through fecal contamination of water or food. Therefore, clean water and proper sanitation are critical to preventing its spread. However, good evidence is lacking as to which mix of interventions (including oral cholera vaccine, case management, and surveillance) is most cost-effective during outbreaks because few high-quality evaluation studies have been conducted ( Taylor and others 2015 ).

Institutional settings—such as schools, health facilities, prisons, and other public settings such as refugee camps and public markets—can pose high risks if water and sanitation are not well managed. Studies have documented higher rates of diarrheal disease and gastrointestinal infection in schools that lack access to improved drinking water and sanitation facilities ( Jasper, Le, and Bartram 2012 ). Improved hand hygiene is particularly important in institutional settings, given the ease with which infections spread in such environments.

• Helminth Infections

Helminth infections are transmitted in water by fecal matter (schistosomiasis) and in soil by soil-transmitted helminths (STH). Although routine monitoring of infection rates is limited, the large number of prevalence surveys permits global estimates to be made.

One study of helminth prevalence data for 6,091 locations in 118 countries estimated that in 2010, 438.9 million people were infected with hookworm ( Ancylostoma duodenale ), 819.0 million with roundworm ( A. lumbricoides ), and 464.6 million with whipworm ( T. trichiura ) ( Pullan and others 2014 ). Of the 4.98 million years lived with disability (YLDs) attributable to STH, 65 percent of those were attributable to hookworm, 22 percent to A. lumbricoides, and 13 percent to T. trichiura . Most STH infections (67 percent) and YLDs (68 percent) occurred in Asia (Central, East, South, and South-East). A separate study estimated 89.9 million STH infections in school-age children in Sub-Saharan Africa ( Brooker, Clements, and Bundy 2006 ). Annual global deaths are estimated at 2,700 for A. lumbricoides and 11,700 for schistosomiasis ( Lozano and others 2010 ).

Helminth infections cause several adverse health outcomes, including anemia, malnutrition, growth stunting, and impaired physical and cognitive development; those outcomes result in low school attendance and educational deficits, thus leading to loss of future economic productivity ( Victora and others 2008 ). The risk of STH infection is greatest for those in specific occupations and circumstances, such as people who work in agriculture, who live in slums, who are poor, who have poor sanitation, and who lack clean water ( Hotez and others 2006 ).

• Undernutrition and Environmental Enteric Dysfunction

Undernutrition causes an estimated 45 percent of all child deaths ( Black and others 2013 ) and is responsible for 11 percent of global disease burden ( Black and others 2008 ). Inadequate dietary intake and disease are directly responsible for undernutrition; however, multiple indirect determinants exacerbate these direct causes, including food insecurity, inadequate child care practices, low maternal education, poor access to health services, lack of access to clean water and sanitation, and poor hygiene practices ( UNICEF 1990 ). Political, cultural, social, and economic factors play a role as well. Stunting (height-for-age below minus two standard deviations from median height-for-age of reference population) and underweight (weight-for-age below minus two standard deviations from median weight-for-age of reference population) are forms of undernutrition associated with weakened immune systems and severe long-term consequences that include poor cognitive development, a lower rate of school attendance, a lower level of job attainment, and a potentially higher risk of chronic disease in adulthood ( Victora and others 2008 ).

The links between diarrhea and child undernutrition ( Fishman and others 2004 ; Prüss-Ustün and Corvalan 2006 ) and other enteric infections ( Brown, Cairncross, and Ensink 2013 ; Checkley and others 2008 ; Guerrant and others 2008 ; Lin and others 2013 ) are well documented. An emerging body of evidence suggests that a subclinical condition of the small intestine caused by chronic ingestion of pathogenic microorganisms results in nutrient malabsorption. This subclinical condition may be the primary causal pathway between poor WASH and child growth ( Humphrey 2009 ).

The evidence on the etiology of diarrheal disease finds an association between levels of intestinal inflammation detected through fecal samples and subsequent growth deficits in infants. This evidence lends support to the environmental enteropathy hypothesis that stunting may be an outcome of frequent enteric infection and intestinal inflammation ( Kotloff and others 2013 ). Because of the asymptomatic nature of environmental enteropathy, the extent and seriousness of the condition is not known; however, it appears to be nearly universal among those living in impoverished conditions ( Salazar-Lindo and others 2004 ) and may be the cause of up to 43 percent of stunting ( Guerrant and others 2013 ).

The risks of low birth weight and stunting are heightened in undernourished mothers ( Özaltin, Hill, and Subramanian 2010 ), resulting in intergenerational consequences of undernutrition and related conditions.

• Social Welfare Consequences

Improved water supply and sanitation provide individuals with increased comfort, safety, dignity, status, and convenience, and also have broader effects on the living environment ( Hutton and others 2014 ). The social welfare effects are difficult to quantify, given their subjective nature. Nevertheless, those benefits are consistently cited as among the most important for beneficiaries of water supply and sanitation ( Cairncross 2004 ; Jenkins and Curtis 2005 ) and may be particularly relevant for women ( Fisher 2006 ).

• In or Near Homes

Water supply in or adjacent to homes provides greater comfort to household members, notably women and girls tasked with fetching water; water sources closer to home, especially piped water, are associated with increased use ( Howard and Bartram 2003 ; Olajuyigbe 2010 ).

Data from 18 countries indicate that women are five times more likely than men to have the responsibility for collecting household water ( WHO and UNICEF 2012b ). As the distance to the water source increases, the time that women could spend on income-generating activities, household chores, and child care decreases ( Ilahi and Grimard 2000 ). A regular piped water supply can introduce the possibility of purchasing time- and labor-saving devices, such as washing machines and dishwashers. Although access to water infrastructure does not always translate into wage employment for women ( Lokshin and Yemtsov 2005 ), one study finds that it can provide time savings in water collection, thus improving gender equality ( Koolwal and Van de Walle 2013 ).

Individuals with access to on-plot sanitation benefit from greater privacy, comfort, and convenience. Accompanying a child to the toilet is more convenient if it is nearby and safe, and mothers can comfortably step away from household duties to practice hygiene. In Ghana, more than 50 percent of households considering adopting a toilet included convenience in their top three reasons for investing in sanitation ( Jenkins and Scott 2007 ). In six countries of South-East Asia, the rural households that owned their own latrine saved from 4 to 20 minutes of travel time per trip ( Hutton and others 2014 ). Privacy, comfort, and convenience benefits are magnified for vulnerable groups, such as the elderly or persons living with disabilities or debilitating chronic illness.

On-plot sanitation reduces the risk of theft or assault (including rape and sexual harassment), especially at night or in isolated locations. Improved pit latrines are safer, less likely to collapse, and easier for small children to use. On-plot water supply and sanitation help to avoid conflicts with neighbors, landowners, or others over the use of shared water resources and sanitation facilities and the use of fields or rivers for open defecation.

• Schools and Workplaces

Access to improved WASH services in schools and workplaces contributes to school attendance, school performance, and choice of where to work, especially for girls and women. Recent evidence from India shows that a national government program to build toilets in schools led to an 8 percent increase in enrollment among pubescent-age boys and girls and a 12 percent increase among younger children of both genders ( Adukia 2014 ). The comparably large effect of school sanitation on primary school children and the robust effects for boys and girls at all ages suggest that at least some of the effect of school sanitation is related to health ( Jasper, Le, and Bartram 2012 ). Research has seldom analyzed academic performance as an outcome; however, given the role that improved water and sanitation have on child health and school attendance rates, the current evidence lacks research into their role in academic performance.

• Menstrual Hygiene

Menstrual hygiene management (MHM) is a poorly understood and underresearched area of WASH services. This neglect has left women in many LMICs without access to appropriate products, facilities, and services ( Sebastian, Hoffmann, and Adelman 2013 ). Lack of adequate MHM is frequently described as a hindrance to girls’ education, but high-quality evidence is lacking ( Sumpter and Torondel 2013 ). A randomized controlled trial in Nepal suggests that menses, and poor menstrual hygiene technology in particular, has no effect on absenteeism of girls; girls miss less than one school day a year on average because of menstruation ( Oster and Thornton 2011 ). However, girls may avoid going to school while they are menstruating, not because they lack management methods but because they lack proper facilities for managing menses ( Jasper, Le, and Bartram 2012 ).

• Environmental Consequences

Two major environmental consequences of poor WASH practices are (1) the excessive extraction of water to meet population needs and (2) the pollution caused by poorly managed human excreta.

The water supply for domestic use represents a small proportion of overall extraction, but the concept of virtual water trade 6 has led to a greater understanding of the implications of population consumption patterns for water use. Globally, the combined effects of socioeconomic growth and climate change indicate that, by 2050, the population at risk of exposure to at least a moderate level of water stress could reach 5 billion people ( Schlosser and others 2014 ). A population of up to an estimated 3 billion in 2050 is nearly double the current estimate of 1.7 billion people who live in areas with a high degree of water stress. The projections are made on the basis of a risk metric of frequency of water shortage in reservoirs ( Sadoff and others 2015 ). This metric combines hydrological variability and water usage trends, which may be mitigated by storage infrastructure. This class of water insecurity is most severe in South Asia and Northern China, although the risk of water shortage exists on all continents.

Overextraction of groundwater and pollution of local surface water bodies have led many large urban population centers to source municipal water supplies from reservoirs or rivers that are tens or hundreds of kilometers from the site of treatment or consumption. Such schemes cost tens of millions of dollars each in reservoir construction, pipeline, and pumping costs. Groundwater resources are under increasing stress from unsustainable agricultural practices resulting from crop choice and energy subsidies to enable farmers to pump groundwater. In India and Mexico, for example, subsidized electricity and kerosene for farmers have led to serious groundwater overdraft ( Scott and Shah 2004 ).

Poorly managed human excreta have major environmental consequences; excreta pollute human settlements, groundwater, and surface water such as lakes, rivers, and oceans. The degree of pollution depends on wastewater, sludge, and sewage management practices; climatic factors; and the population size and density in relation to the volume of water. In highly populated river basins, municipal sewage and wastewater contribute a high proportion to overall biological oxygen demand ( Corcoran and others 2011 ; Rabalais and Turner 2013 ).

Heavily polluted surface water has serious effects on ecosystems, food webs, and biodiversity ( Turner and Rabalais 1991 ). Coastal areas that are near the discharge of large, polluted rivers have reported compromised fish catch, such as in Argentina ( Dutto and others 2012 ). In the coastal areas of the Philippines, water pollution was estimated to cost US$26 million per year in lost fish catch and degraded coral reefs ( World Bank 2009 ). Water pollution of recreational areas affects the tourism industry, thus lowering visit rates or causing gastrointestinal illness or both.

• Financial and Economic Consequences

Financial and economic studies convert the health, social, and environmental effects of poor WASH to a common money metric, thereby enabling aggregation as well as comparison across locations and over time. However, these estimates are often incomplete, using crude estimates of economic value or relying on the imprecise physical effects underlying the economic values.

Damage cost studies account for the broader welfare and productivity consequences of poor WASH beyond the health effects. A review of economic impacts of poor water and sanitation found estimates from more than 30 countries (see annex 9A), as well as global studies. Studies with economic impacts expressed as a percentage of gross domestic product (GDP) are shown in figure 9.4 , disaggregated between health and nonhealth damages.

Economic Costs of Poor Water and Sanitation in Selected Countries, as a Percentage of GDP.

Although all the studies presented in figure 9.4 present effects in monetary units, the results are not directly comparable. They have different base years and different effects included; some include only sanitation, and others include water and sanitation. In East Asian and Pacific and Sub-Saharan African economies, the cost of poor sanitation exceeded 2 percent of total GDP; in South Asia, it exceeded 4 percent of GDP. A global study, including the health and time losses, valued the costs in LMICs at 1.5 percent of global domestic product ( Hutton 2012 ). These significant economic effects raise awareness of the extent of the problem, but they do not indicate how to address the problem in a cost-effective manner.

• Intervention Options and Effectiveness

Three main categories of interventions to improve WASH are as follows:

• Technology options and WASH practices cover the type of hardware, equipment, and associated behaviors of WASH services. Not all water or sanitation technologies perform the same function, so they can be classified by the service level they provide.
• Service delivery models cover the components of WASH service implementation. Those components include (1) approaches to demand generation and WASH behavior change, (2) approaches to strengthen supply of water and sanitation goods and services, and (3) approaches to improve the effectiveness of WASH service delivery.
• Strengthening the enabling environment for WASH service delivery includes (1) measures to strengthen capacity, (2) legal framework, (3) policy and planning, (4) resource allocation, (5) monitoring and evaluation, and (6) other interventions to provide a stronger foundation for implementing the technology and service delivery models. The evidence is provided in annex 9B.
• Effectiveness of Technologies and Practices

Water technologies are designed to source, treat, distribute, and monitor the supply of water. Epidemiological studies evaluate the effectiveness of water interventions in terms of the quantity and (microbial) quality of water supplied ( Waddington and others 2009 ). Increasing evidence enables the comparison of the incremental health benefits of different water interventions, such as improved community source, piped water, higher-quality piped water, and point-of-use treatment (chlorine, solar, and filter). Utility regulators, as well as regional and global initiatives, monitor water quality according to service standards, such as continuity, consumption, and number of complaints ( IBNET 2014 ). In 2010, The International Benchmarking Network for Water and Sanitation Utilities (IBNET) of the World Bank reported that only 16 percent of utilities in low-income countries supply water continuously 24 hours per day, compared to 86 percent of utilities in middle-income countries ( Van den Berg and Danilenko 2010 ). Even a few days of interrupted water supply can result in significant adverse health consequences if beneficiaries revert to using unimproved sources of water ( Hunter, Zmirou-Navier, and Hartemann 2009 ).

To increase safety, drinking water can be treated either at the source or at the point of use through a process of filtration or disinfection or both. The greatest health effects for improved water treatment technologies concern the piped water supply, with greater health benefits associated with higher-quality piped water (water that is safe and continuously available) ( Wolf and others 2014 ). Among household-level studies, filter interventions that also provided safe storage (for example, ceramic filters) were associated with a large reduction in diarrheal disease ( Wolf and others 2014 ). Neither chlorine treatment nor solar disinfection shows significant impact on diarrhea after meta-analysis adjusted for non-blinding of the intervention ( Wolf and others 2014 ), although an earlier systematic review and meta-analysis of water quality interventions found household-level treatment to be more effective than source treatment ( Clasen and others 2005 ). Blinding participants to the intervention and longer follow-up periods are recommended to better understand the impact of point-of-use water treatment interventions on diarrhea ( Clasen and others 2005 ).

To reduce the transmission of pathogens, sanitation technologies isolate, transport, and treat fecal waste, and they also provide users with a dignified and comfortable experience when going to the toilet. Different rungs on the “sanitation ladder” confer different health impacts and user experiences; hence, utilization of different kinds of sanitation services or facilities can vary. For example, communal facilities may be poorly maintained, in which case they are less likely to be used by women, children, and individuals who are disabled or infirm. Distance also decreases usage of communal toilets ( Biran and others 2011 ).

Hygiene technologies enable users to perform basic personal hygiene functions. Epidemiological studies have typically used the presence of a place for handwashing with soap and water as a proxy for handwashing practice; however, this has been shown to be only loosely correlated with observed handwashing behavior ( Ram 2013 ).

One synthetic review and meta-analysis of health impact assessments of water and sanitation interventions includes 61 individual studies for water, 12 observations comparing unimproved and improved sanitation conditions, and only 2 observations comparing unimproved sanitation and sewer connections ( Wolf and others 2014 ).

Table 9.4 shows relative risk reductions for different movements up the water supply and sanitation ladders. The summary risk ratio for all observations on diarrhea morbidity is 0.66 (95% confidence interval [CI]: 0.60–0.71) for water interventions and 0.72 (95% CI: 0.59–0.88) for sanitation interventions ( Wolf and others 2014 ). An earlier review of 25 studies investigating the association between sewerage and diarrhea or other related outcomes estimated an average risk ratio of 0.70 (95% CI: 0.61−0.79), which increased to as much as 0.40 when starting sanitation conditions were very poor ( Norman, Pedley, and Takkouche 2010 ).

Meta-Regression Results for Water and Sanitation Interventions: Relative Risks Compared with No Improved Water, Sanitation, or Hygiene Practice.

A meta-analysis of hygiene interventions found an average risk ratio for diarrhea of 0.60 for promotion of handwashing with soap (95% CI: 0.53–0.68) and 0.76 for general hygiene education alone (95% CI: 0.67–0.86) ( Freeman and others 2014 ). These results are summarized in table 9.4 . An earlier systematic review found a relative risk compared to no handwashing of 0.84 (95% CI: 0.79–0.89) for respiratory infection ( Rabie and Curtis 2006 ).

A meta-analysis that combined sanitation availability and use examined the impact of improved sanitation on soil-transmitted helminths. The meta-analysis reported the following overall odds ratios: 7 0.51 (95% CI: 0.44–0.61) for the three soil-transmitted helminths combined, 0.54 (95% CI: 0.43–0.69) for A. lumbricoides , 0.58 (95% CI: 0.45–0.75) for T. trichiura , and 0.60 (95% CI: 0.48–0.75) for hookworm ( Ziegelbauer and others 2012 ).

Access to sanitation has been associated with lower trachoma, as measured by the presence of trachomatous inflammation–follicular or trachomatous inflammation–intense with odds ratio 0.85 (95% CI: 0.75–0.95) and C. trachomatis infection with odds ratio 0.67 (95% CI: 0.55–0.78) ( Stocks and others 2014 ).

A systematic review examined the impact of improved WASH on child nutritional status. Specifically, a meta-analysis of five randomized controlled trials found a mean difference of 0.08 in height-for-age z-scores of children under age five years (95% CI: 0.00–0.16) for solar disinfection of water, provision of soap, and improvements in water quality ( Dangour and others 2013 ). However, the authors raised concerns about the low methodological quality of the included studies and the short follow-up periods; there was insufficient experimental evidence on water supply improvement and sanitation to include in the meta-analysis. Since publication of the Dangour and others ( 2013 ) review, several additional randomized controlled trials of household sanitation interventions have been completed ( Briceno, Coville, and Martinez 2014 ; Cameron, Shah, and Olivia 2013 ; Clasen and others 2014 ; Hammer and Spears 2013 ; Patil and others 2014 ), most of them failing to find a significant relationship between the interventions and child health or growth outcomes. One exception is a study in rural Mali of Community-Led Total Sanitation (CLTS), which led to taller children on average (+0.18 height-for-age z-score, CI on z-score: 0.03–0.32). These children were 6 percentage points less likely to be stunted after the intervention ( Pickering and others 2015 ). Econometric studies drawing on time series data establish links between open defecation and stunting ( Spears 2013 ), between open defecation and childhood diarrhea in India ( Andres and others 2014 ), and between open defecation and cognitive development in India ( Spears and Lamba 2013 ). A source of regularly updated evidence reviews on WASH interventions with strict inclusion criteria is the Cochrane Library. 8

• Effectiveness of Service Delivery Models

Effectiveness of service delivery models is measured by intervention uptake, change in risky behaviors, sustainability, and, to a lesser extent, health outcomes. Large-scale approaches that include demand raising and behavior change are needed to achieve universal access, but experience has shown these approaches result in lower average effectiveness.

• Approaches to Demand Generation and WASH Behavior Change

Demand-based approaches start from the premise that lasting change is brought about when individual and community behaviors are affected. CLTS and its school-based counterpart, School-Led Total Sanitation (SLTS), promote broader changes in sanitation and hygiene behaviors at the community level. Since its founding in 1999, the CLTS approach has rapidly expanded to more than 50 developing countries, where many thousand successful applications of the approach have been made; at least 16 national governments have adopted CLTS as national policy. 9 Rigorous evaluation of the CLTS approach has been limited, and the reliance on the emergence of natural leaders presents difficulties in testing the effectiveness of CLTS using conventional experimental methods. One exception comes from a recent example in rural Mali, in which CLTS was well implemented in a random set of villages and shown to almost double coverage of a private latrine ( Pickering and others 2015 ).

Specific behaviors, such as household water treatment and storage (HWTS) and handwashing with soap, have been the subject of behavior change campaigns. HWTS combines marketing of low-cost water treatment (for example, boiling, filtration, disinfection using chemicals, solar and ultraviolet lamps, and flocculation) and safe storage technologies with communication- and behavior-change techniques ( Peal, Evans, and van der Voorden 2010 ). Despite substantial evidence pointing to health benefits of HWTS, skepticism remains that the results may largely be the result of bias; concerns remain about the extent of uptake, use, and scalability of commercially marketed HWTS, particularly among poor populations most at risk of diarrheal disease ( Schmidt and Cairncross 2009 ).

Handwashing promotion has been tested in formative research and has applied social cognitive models to determine what motivates and changes behavior. The promotion has used a variety of communication channels—such as television, radio, theater groups, community meetings, and face-to-face visits—to reach target groups who typically are mothers of young children or school-age children. A pre- and post-evaluation of the approach in Burkina Faso, which targeted the behavior of safe disposal of child feces and handwashing after contact, documented increases in handwashing ( Curtis and others 2001 ). A similar approach to improve handwashing behavior was piloted on a large scale under the Water and Sanitation Program’s Global Scaling Up Handwashing Projects in Peru, Senegal, 10 Tanzania, and Vietnam. Experimental evidence from Peru ( Galiani and others 2015 ), Tanzania ( Briceno, Coville, and Martinez 2014 ), and Vietnam ( Chase and Do 2012 ) suggests the campaigns were only marginally successful. The Peru study did find large changes in behavior in a subset of communities with children who participated in a school-based handwashing promotion intervention. Effects on health were not observed in any of the countries, and the sustainability of handwashing was not measured. A key obstacle identified in both Tanzania and Vietnam was the difficult trade-off between scale and intensity of activities.

The Global Public-Private Partnership for Handwashing (PPPHW) combines the marketing expertise of the soap industry with government support and the enabling environment to trigger behavior change and reduce diarrhea. Whereas the PPPHW has expanded globally, the coalition has not yet been subject to rigorous effectiveness trials ( Peal, Evans, and van der Voorden 2010 ). Evaluations of PPPHWs have been commissioned by private soap companies and involved providing free soap to households ( Nicholson and others 2013 ), thus limiting their external validity.

• Approaches to Strengthening Supply of Water and Sanitation Goods and Services

Supply-side approaches to water and sanitation service delivery cover the full value chain from production and assembly of inputs, importation, sales, distribution, installation, and maintenance of water infrastructure and latrines. Services range from micro and small-scale independent water resellers; network operators; well and pit diggers; operators offering masonry, pit, and septic tank emptying; and public toilet operators to medium-scale sanitation markets—or sanimarts—offering a full range of sanitation goods and services. Small-scale operators can effectively serve rural markets, where the majority of people without access to piped water and sanitation live. However, the existing literature highlights several obstacles to growth and the ability of such providers to effectively serve these rural populations.

Rural operators often face higher per capita costs because they lack economies of scale enjoyed by larger utilities and therefore have lower revenue potential ( Baker 2009 ). Investment financing needed for growth can be difficult to secure, and the lack of formalization in the sector can result in insecure operating environments ( Sy, Warner, and Jamieson 2014 ). The availability of alternative sources of free or low-cost water makes rural areas less attractive to independent operators. Low or uneven demand has limited growth opportunities for small-scale onsite sanitation service providers. Despite these obstacles, small-scale service providers are increasingly recognized as a central part of the solution to close the gap in water and sanitation access, particularly among the poor.

Supply-side strengthening is predominant in the Community Approach to Total Sanitation (CATS) promoted by the United Nations Children’s Fund and the Total Sanitation and Sanitation Marketing (TSSM) approach of the World Bank Water and Sanitation Program. Recent randomized control trial impact evaluations of TSSM in Madhya Pradesh, India (which included a hardware subsidy to households below the poverty line); East Java, Indonesia; and 10 rural districts of Tanzania found the approach varied widely in its effectiveness across the countries, with no increase in improved sanitation in Indonesia ( Cameron, Shah, and Olivia 2013 ) and increases of 19 and 15.7 percent in Madhya Pradesh ( Patil and others 2014 ) and Tanzania ( Briceno, Coville, and Martinez 2014 ), respectively. Despite better sanitation coverage in Madhya Pradesh, large numbers of adults continued to practice open defecation.

• Approaches to Improve the Effectiveness of WASH Service Delivery

Addressing the supply- and demand-side constraints of WASH service delivery has led to large increases in access. But the persistence of regional and socioeconomic disparities in access suggests that current delivery models could be improved to enhance the quality of services as well as increase take-up of services, especially among the poorest populations.

Results-based approaches 11 to development that offer financial or nonmonetary rewards upon demonstration of measurable outputs or outcomes are used increasingly for achieving desirable outcomes. The specific details differ, but such approaches share a common aim of shifting the overall incentive structure from financing infrastructure to delivering services. Until recently, the experience using results-based approaches in water and sanitation was limited. A review by the World Bank in 2010 indicated that less than 5 percent of its output-based aid (OBA) portfolio was in water and sanitation ( Mumssen, Johannes, and Kumar 2010 ). The use of OBA has increased under the Global Partnership on Output-Based Aid (GPOBA), which lists 22 projects in water supply and sanitation whose outputs include water, sewerage, or sanitation connections. 12 Multilateral and bilateral agencies such as the World Bank, Inter-American Development Bank, and Department for International Development (DfID) have shifted funding toward results-based approaches in water and sanitation. As of early 2016, the World Bank’s Program-for-Results Financing (PforR) has six active operations in water supply, sanitation, and hygiene.

Microfinance or microcredit can help poor households facing liquidity constraints to invest in water supply and sanitation by (1) smoothing consumption over time, (2) encouraging households to be more willing to adopt improved services, and (3) giving those households an opportunity to purchase more durable, higher levels of service. Consumer credit has been applied successfully to increase the installation and use of household piped water connections ( Devoto and others 2011 ), but experimental evidence of consumer lending for sanitation remains limited. However, emerging interest in the potential of microfinance for household sanitation and the results of small-scale pilots are promising. A randomized study in Cambodia found a fourfold increase in uptake when households were offered a 12-month low-interest loan to purchase a latrine ( Shah 2013 ).

Finally, interest is emerging for using large-scale delivery platforms for social services and poverty reduction. These platforms can help improve the targeting of WASH services and will make use of the tools and mechanisms those programs have for improving livelihoods and outcomes for the poor. Examples include the following:

• Sanitation subsidies and financing can be targeted to conditional-cash transfer (CCT) participants, many of whom lack adequate sanitation. A more ambitious approach could make receipt of cash transfers conditional on a household’s use of improved sanitation. These programs also provide outreach and counseling to reach target households with sanitation promotion messages that build awareness and help change behavior.
• Community-driven development (CDD) programs can be used as a platform to deliver CLTS and to follow up with participatory planning and budgeting to ensure that communities become free of open defecation.
• Safety-net programs that build skills and strengthen sources of livelihood can include sanitation businesses and services such as masonry, plumbing, and electrical skills among the list of profitable investments for beneficiaries.
• Many nutrition interventions already promote handwashing with soap, safe water, and sanitation. Handwashing demonstrations are often included in promotions for breastfeeding and interventions for feeding infants and young children, which also stress the use of safe water in food preparation.

More innovative integration approaches may use those same channels to discuss with the community sanitation product options and services that are available. Evidence is needed on the effectiveness and the cost of integrated approaches. Such information may highlight the need for more operational research and impact evaluations to inform policy and program design.

• Intervention Costs, Efficiency, and Sustainability

Any intervention in the WASH sector requires an economic rationale, thus satisfying conditions of efficiency, affordability, and relevance. Cost-benefit analysis compares the intervention costs with the benefits, expressed in monetary units. Cost-effectiveness analysis compares the intervention costs with the benefits, expressed in some other common unit, such as lives gained or pollution load to the environment averted.

The cost of interventions is one key piece of evidence for decision making, because it is relatively easy to obtain and is often cited as a constraint for an investment decision, whether by governments, private sectors, households, or individuals. Costs can be measured for the WASH technology (the hardware), the service delivery approach (the “software” or program management), and the enabling environment.

Despite its importance, cost information is not commonly tabulated in an appropriate format to support decision making. At the policy level, budgets and resource allocations are fragmented among subsectors, levels of government, and sector partners or financiers. Considerable differences exist between budget allocations and disbursements. WASH-BAT (bottleneck analysis tool), developed by UNICEF, helps consolidate the budgetary needs so that sector bottlenecks can be removed (see annex 9B) ( UNICEF 2014 ). At the program or service delivery levels, implementers do not easily share information on their costs, and budgets may not be structured for simple breakdowns between software and hardware costs. Cost studies for WASH technologies are more abundant, and at the local level, the market or subsidized price is available. However, the price is rarely the same as the cost. The price commonly contains either a profit or a subsidy; because both are transfer payments, they should be excluded from economic analysis. However, to ease the research burden, it is common practice in economic analysis to use prices as a proxy for cost, adjusting for any known subsidy or profit.

Published cost evidence is available in aggregated and unit forms. Aggregated cost includes the expenditure required to meet specified targets. The World Bank estimates that the global capital costs of achieving universal access to WASH services by 2030 are US$28.4 billion per year confidence interval [CI]: US$13.8 billion to US$46.7 billion) from 2015 to 2030 for basic WASH and $114 billion per year (CI: US$74 billion to US$166 billion) for safely managed WASH ( Hutton and Varughese 2016 ). 13 Those costs are equivalent to 0.10 percent of global product for basic WASH and 0.39 percent of global product for safely managed WASH, including 140 LMICs. Those needs compare with 0.12 percent of its gross product spent on meeting the MDG water target and making progress toward the sanitation target. Universal basic access by 2030 is feasible at current spending but requires reallocations to sanitation, to rural areas, and to off-track regions. However, substantial further spending is needed to meet the higher standard of safely managed services. The costs as a proportion of gross regional product are shown by MDG region in figure 9.5 . Regions most challenged to reach universal access are South Asia and Sub-Saharan Africa.

Costs of Basic and Safely Managed Services as a Percentage of GRP, by Region, with Uncertainty Range.

Many countries also produce investment plans for meeting national targets, thereby focusing on the financing the government will provide. The Organisation for Economic Co-Operation and Development (OECD) has created FEASIBLE, a tool for developing national financing strategies by comparing the costs of meeting national targets with the projected financing available. 14 FEASIBLE has been applied in at least 12 countries ( OECD 2011 ).

A key input to these aggregated studies is the unit costs of WASH provision at the household or community level. Because of climatic, topographical, and socioeconomic differences, the costs of providing service vary highly between studies, contexts, and levels of service. The costs per cubic meter of water and of wastewater services, as well as average monthly household bills, are available for utility services through national regulators, regional associations, and global initiatives ( IBNET 2014 ). Studies commonly compare the cost of different sources of water supply, and they find piped water to be significantly cheaper per unit compared with vendor-supplied water. However, those studies find monthly expenditure is more similar between the two sources because of higher consumption of piped water than of other water sources ( Whittington and others 2009 ). The IRC WASHCost project calculated benchmark capital and recurrent costs for basic levels of water service in Andhra Pradesh, India; Burkina Faso; Ghana; and Mozambique ( Burr and Fonseca 2013 ). Benchmark capital costs ranged from US$20 per person for boreholes and hand pumps to US$152 for larger water schemes. Benchmark recurrent costs ranged from US$3 to US$15 per person per year, but actual expenditures were substantially lower. Construction cost for equivalent latrines varies widely between settings ( Hutton and others 2014 ). Comparison of alternative sanitation transportation and treatment technologies also provides important policy direction; in general, fecal sludge management is considerably cheaper than sewerage, as in Dakar, Senegal, where it was found to be five times cheaper ( Dodane and others 2012 ). Extrapolating available data from one context to another carries risks. Therefore, simple costing tools and investment in evidence gathering are required so that cost estimates of specific locations can be made. 15

Ideally, those who determine the costs of water supply and sanitation services would consider the externalities and the long-run cost of supply. One study provides an illustrative example of the full costs of water supply and sanitation (including opportunity costs and environmental costs) with the low costs, varying from a high of US$2.00 per cubic meter to a low of US$0.80 per cubic meter ( table 9.5 ) ( Whittington and others 2009 ).

Cost Estimates of Improved Water and Sanitation Services. US$ per cubic meter

From a policy perspective, the affordability and willingness to pay for those costs is a critical issue. A global review found that water supply costs as a proportion of household income are significantly higher for poorer populations ( Smets 2014 ) and well above the benchmark of between 3 percent and 5 percent used by some governments and international organizations.

WASH services have a large array of welfare and development benefits. Table 9.6 classifies those benefits under health, convenience, social, educational, reuse, water access, and other.

Benefits of Improved Drinking Water Supply and Sanitation.

Those benefits have been evaluated extensively, but few studies evaluate the benefits comprehensively. The most robust scientific studies, such as randomized or matched prospective cohort studies, have been conducted on health effects. But only few of those studies exist, and economic variables are rarely captured. The majority of economic studies build models filled with data from a mixture of sources. Global studies assessing the economic benefits of improved water supply and sanitation include health economic benefits and convenience time savings ( Hutton 2013 ; Whittington and others 2009 ). Country studies have also evaluated the value of health and time savings ( Pattanayak and others 2010 ). Regional studies from Southeast Asia assess the water access, reuse, and tourism benefits of improved sanitation as a proportion of avoided damage costs ( Hutton and others 2008 , 2014 ).

Willingness-to-pay (WTP) studies have estimated the economic value of water quality improvements, but only very few studies use experimental methods ( Null and others 2012 ). Other studies have assessed WTP to avoid health impacts ( Guh and others 2008 ; Orgill and others 2013 ) and to receive piped water ( Whittington and others 2002 ). A systematic review of those studies has shown that the economic value derived from the WTP for improved water quality is less than the cost of producing and distributing it ( Null and others 2012 ). Social benefits have been assessed, but few have been expressed in money values except WTP studies, which tend to capture all benefits and make differentiating social from other benefits difficult.

Economic value is associated with river cleanup that includes improved management of municipal wastewater, as well as improved management of industrial discharge, agricultural runoff, and solid waste. The financial viability of WASH services has been expressed in terms of financial returns. The most comprehensive source of data is from projects of multilateral development banks that routinely conduct a financial assessment of WASH services before project approval and that, in some cases, report on the completion of project implementation.

• Intervention Efficiency: Cost-Benefit Analysis

The discussion of efficiency should distinguish between cost-benefit analysis, which uses a common money metric for all costs and benefits, and cost-effectiveness analysis, which compares interventions for one type of outcome. Reviewed cost-benefit studies are provided in annex 9C.

Efficiency studies can be conducted in two ways ( Whittington and others 2009 ):

• By generating estimates of cost and benefit in specific sites or field studies for the purposes of either evaluating intervention performance or selecting a site for a future project ( Kremer and others 2011 )
• By using model costs and benefits for specific sites or larger jurisdictions, such as country or global level, and best-available evidence from multiple sources ( Hutton 2013 ; Whittington and others 2009 )

Given the high costs and challenges associated with collecting all the cost and benefit data required for the first approach, it is common practice to combine site-specific values with data extrapolated from other sources ( Hutton and others 2014 ). Table 9.7 shows the most recently available global studies that have modeled selected water supply and sanitation interventions. One important finding from these studies is that lower technology interventions have higher returns than more expensive networked options.

Benefit-Cost Ratios from Global Studies.

Global studies indicate the projected overall costs and benefits from intervention alternatives, but they are not particularly useful in guiding decisions on which technology and service level to choose in specific settings. One randomized implementation study in India finds similar health costs between study arms. However, it finds statistically significant savings in time in the intervention group of US$7 per household (US$5 for water and US$2 for sanitation) during the dry season, or roughly 5 percent of monthly cash expenditures ( Pattanayak and others 2010 ). A study from South Africa estimates a benefit-cost ratio of 3.1 for small-scale water schemes ( Cameron and others 2011 ). A study from Indonesia compared three wastewater treatment interventions and finds limited economic rationale for the interventions ( Prihandrijanti, Malisie, and Otterpohl 2008 ). However, a broader cost-benefit study at the river basin level estimated the benefits of cleaning up the Upper Citarum river in Indonesia exceeded costs by 2.3 times ( Hutton and others 2013 ).

Targeting the poor could be justified; children from poorer households are at increased health risk because they live in communities with lower access to improved water and sanitation facilities. A study in Bangladesh, India, and Pakistan estimating the cost per episode for income quintiles shows that costs of an illness represent a higher proportion of income for lower quintiles ( Rheingans and others 2012 ).

The cost efficiency of technologies depends on the local geological setting, population density, and number of households to be served. Large water distribution and sewerage systems may only be cost efficient if they serve large, dense populations. Providing water service on a smaller scale through either communal or in-compound wells or boreholes and onsite household sanitation may be a more appropriate and cost-efficient service level for sparsely populated areas ( Ferro, Lentini, and Mercadier 2011 ).

• Intervention Efficiency: Cost-Effectiveness Analysis

The main outcomes used in cost-effectiveness studies are health and environmental outcomes. When used to compare programs in a sector, cost-effectiveness can be measured by program outcomes, such as the number of latrines constructed, the number of water connections installed, or the percentage of beneficiaries changing behavior. For water supply interventions, health cost-effectiveness studies have been conducted (see annex 9C). Studies focus on improved water supply according to the JMP definition and point-of-use treatment by households or schools. A global study compares water supply interventions at the regional level ( Clasen and others 2007 ).

Figure 9.6 shows the cost per healthy life-year (HLY) gained for four interventions in two regions. It shows that the selected interventions vary by a factor of approximately 2.5 between the most cost-effective (chlorination) and the least cost-effective (ceramic filter). However, all interventions have a cost per HLY that is below the GDP of countries in these regions, thereby indicating a cost-effective use of health resources. Another global study found the incremental costs averted of adding point-of-use water disinfection on top of improved water supply costs resulted in a cost per DALY averted of less than US$25 in Sub-Saharan Africa, of US$63 in India and Bangladesh, and of less than US$210 in South-East Asia and the Western Pacific ( Haller, Hutton, and Bartram 2007 ).

Cost Per HLY Gained from Four Water Supply and Water Quality Interventions in Two World Subregions, US$, 2005.

Fewer studies have conducted health cost-effectiveness analyses of sanitation and hygiene interventions. Two global studies by the WHO and World Bank examine the cost-effectiveness of water supply and sanitation combined ( Günther and Fink 2011 ; Haller, Hutton, and Bartram 2007 ). Using regions defined by epidemiological strata, WHO estimates that the cost in countries with high child and high adult mortality is less than US$530 per DALY averted in the Eastern Mediterranean and Middle East, US$650 in Sub-Saharan Africa, US$1,400 in South and South-East Asia, and US$2,800 in Latin America and the Caribbean. A World Bank study on child mortality reduction estimates the average cost per life year saved in Sub-Saharan African countries is US$1,104 for basic improved water and sanitation and is US$995 for privately piped water and flush toilets ( Günther and Fink 2011 ).

In country studies in South-East Asia, the cost per DALY averted of basic sanitation is less than US$1,100 in selected rural areas of Cambodia, China, Indonesia, the Lao People’s Democratic Republic, and Vietnam; the exception is in the Philippines, where it is US$2,500 ( Hutton and others 2014 ). Few recent country-specific studies are available on hygiene interventions; one study from Burkina Faso estimates a cost of US$51 per death averted for health education to mothers ( Borghi and others 2002 ).

Sustainability of water supply, sanitation, and hygiene is covered in annex 9D; financing is covered in annex 9E.

• Conclusions

Although global deaths from diarrhea have declined significantly over the past 20 years, poor water supply, sanitation, and hygiene are still responsible for a significant disease burden. An estimated 842,000 global deaths in 2012 were due to diarrhea caused by poor WASH. Other less well-quantified but important long-term health consequences of poor WASH, such as helminths and enteric dysfunction, remain. Those diseases affect children’s nutritional status, thereby inhibiting growth and mental development. Overall, the health impacts of poor WASH lead to economic consequences of several percent of GDP and continue to significantly affect quality of life and the environment. Furthermore, water stress is a growing phenomenon that will affect at least 2.8 billion people in 48 countries by 2025. Climatic factors are harder to control, but water scarcity can be mitigated by changing water use patterns and reducing pollution of surface waters.

Important progress has been made in achieving the MDG global water and sanitation targets. In September 2015, new global targets for universal access to safe WASH were adopted. At the current rates of progress and using current indicators, achieving those targets will take at least 20 years for water supply and 60 years for sanitation ( WHO and UNICEF 2014 ). Covering the poor and marginalized populations will continue to be a challenge; the remaining unserved populations are likely to be harder to reach as universal access is approached. The service level benchmark of targeting safely managed services will require better policy and regulatory frameworks and more resources. Indeed, as environmental consequences intensify and populations demand a higher quality of service, a higher target for service level will be increasingly required. This demand will raise questions about priorities; countries will face a trade-off between (1) dedicating policy space and spending public subsidies to move populations that are already served higher up the water and sanitation ladder and (2) reaching populations that are not served with basic WASH services. Each country will have its unique set of challenges. The human right to drinking water and sanitation can serve as a reminder that priority should be given to ensuring at least a minimum level of affordable WASH service for all citizens.

Populations are growing and moving, economies are developing and becoming richer, and the climate is changing. Each one has its challenges and opportunities. Population migration to greenfield sites offers a chance of implementing new and appropriate technologies, and selection of cost-effective and affordable technologies in urban planning is essential. Economic growth leads to greater tax revenues for local governments and increased ability to upgrade infrastructure and expand urban renewal. Climate change challenges the delivery of WASH services by affecting rainfall patterns, freshwater availability, and frequency of heat events, and it exacerbates health risks. However, this new threat, when taken seriously, can be an opportunity to overhaul outdated policies and technologies. Furthermore, as nutrient sources for chemical fertilizer become scarcer, price increases will force suppliers to seek alternatives; the price of composted sludge is expected to increase, thereby attracting investments. New research, data, and technologies are increasingly available to present new possibilities for addressing entrenched problems in the WASH sector.

The following research priorities are recommended for immediate attention:

• To adequately address equity considerations in the SDG era, there is a need to understand where poor people live and what their levels of access are. Disaggregated data on the underserved—including slum populations, ethnic groups, women, elderly, and persons with disabilities—can support prioritization. Greater focus is needed on how to increase access in the lagging regions of South Asia and Africa, where a large proportion of the unserved live. At the country level, policy and financial incentives need to be aligned and the economic arguments made for allocating resources to WASH services.
• More evidence is needed to support the emerging understanding of the wider health effects of water, sanitation, and hygiene. Multisectoral approaches will become more important as the complementarities among WASH, health, and nutrition are better understood. Further, rigorously designed and controlled studies are needed to quantify these benefits, including the measurement of cost-effectiveness to guide policy and program design.
• The social welfare consequences of poor WASH are not well documented but are potentially very large. In particular, a greater understanding is needed of the gender effects of inadequate WASH and of how improved WASH services contribute to gender equality.
• A large part of the remaining challenge of improving access to sanitation and hygiene is behavioral rather than technical. However, little evidence exists on the effectiveness of behavior change using conventional methods at scale or on the transferability of behavior change interventions that are successful in a particular context. A better understanding of habit formation and what leads to sustainable behavior change is needed.
• Innovative delivery platforms that leverage national poverty reduction programs, such as CCT and CDD programs, have the potential to achieve wide coverage at little marginal cost. Such approaches can also provide the methodology and data sources to support targeting areas of poverty in WASH services.
• A better understanding is needed on which WASH interventions work in slum areas and low-income neighborhoods and under what conditions the interventions work.
• A greater understanding is needed of how output-based incentives can be used to improve WASH service delivery and to lead to greater sustainability of services.
• Innovations in subsidies and microfinance are needed to ensure that the poor gain access to improved sanitation. Despite greater availability and lower cost of sanitation goods and services, some people remain too poor to afford adequate water supply and sanitation. Such populations should be identified to receive hardware and financial subsidies.

The annexes to this chapter are as follows. They are available at http://www.dcp-3.org/environment .

• Annex 9A. Overview of Studies Presenting Damage Costs of Poor Water, Sanitation, and Hygiene at the National Level
• Annex 9B. Effectiveness of Enabling Environments
• Annex 9C. Cost-Effectiveness and Cost-Benefit Studies on Water, Sanitation, and Hygiene
• Annex 9D. Intervention Sustainability
• Annex 9E. Intervention Financing

Corresponding author: Guy Hutton, WASH Section, UNICEF. gro.fecinu@nottuhg , formerly at the Water and Sanitation Program, World Bank.

• Low-income countries (LICs) = US$1,045 or less
• Middle-income countries (MICs) are subdivided: a) lower-middle-income = US$1,046 to US$4,125 b) upper-middle-income (UMICs) = US$4,126 to US$12,745
• High-income countries (HICs) = US$12,746 or more.

United Nations Human Rights Council, Resolution 18/1, “The Human Right to Safe Drinking Water and Sanitation,” adopted September 28, 2011, http://www ​.worldwatercouncil ​.org/fileadmin ​/wwc/Right_to_Water ​/Human_Rights_Council ​_Resolution_cotobre_2011.pdf .

United Nations Human Rights Council, Resolution 18/1.

Whereas no academic literature is available with such examples, national surveys (such as the Demographic and Health Survey or the Multiple Indicator Cluster Survey) show that a higher proportion of households practice unsafe management of children’s feces as compared with overall household unimproved sanitation practices.

JMP reports for country data and additional breakdowns are available at http://www ​.wssinfo.org .

Characterized by villous atrophy, crypt hyperplasia, increased permeability, inflammatory cell infiltrate, and modest malabsorption.

The hidden flow of water if food or other commodities that require water to be produced are traded from one place to another.

An odds ratio (OR) is a measure of association between an exposure and an outcome. The OR represents the odds that an outcome will occur given a particular exposure, compared with the odds of the outcome occurring in the absence of that exposure.

For more on the Cochrane Library, see http://www ​.thecochranelibrary.com .

For more information on CLTS, see http://www ​.communityledtotalsanitation ​.org ​/page/clts-approach and http: ​//cltsfoundation.org/clts-map.html .

The impact evaluation in Senegal was compromised because of contamination of the treatment group with the handwashing with soap intervention group.

Examples of results-based approaches include the following: output-based aid (OBA), results-based financing (RBF), pay-for-performance (P4P), program for results (PforR), and conditional-cash transfer (CCT).

Accessed March 31, 2014, through the OBA website, https://www ​.gpoba.org .

Basic water: percentage of population using a protected community source or piped water with a total collection time of 30 minutes or less for a round-trip, including queuing (same as JMP improved definition except time criteria has been introduced). Basic sanitation: percentage of population using a basic private sanitation facility (same as JMP improved definition). Basic hygiene: percentage of population with handwashing facilities with soap and water at home. Safely managed water: percentage of population using safely managed drinking water services. Corresponds to population using an improved drinking water source located on the premises, available when needed, and free of fecal and priority chemical contamination. Safely managed sanitation: percentage of population using safely managed sanitation services. Includes safe onsite isolation, extraction, conveyance, treatment and disposal, or reuse.

For information about the OECD’s methodology and FEASIBLE computer model, see http://www ​.oecd.org/env ​/outreach/methodologyandfeasiblecomputermodel.htm (accessed November 11, 2015).

For example, the IRC International Water and Sanitation Center has developed the WASHCost Calculator ( www ​.ircwash.org/washcost ), whereas the World Bank’s Economics of Sanitation Initiative has developed an economic assessment toolkit under the Economics of Sanitation Initiative ( http://www ​.wsp.org/esi ).

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• Cite this Page Hutton G, Chase C. Water Supply, Sanitation, and Hygiene. In: Mock CN, Nugent R, Kobusingye O, et al., editors. Injury Prevention and Environmental Health. 3rd edition. Washington (DC): The International Bank for Reconstruction and Development / The World Bank; 2017 Oct 27. Chapter 9. doi: 10.1596/978-1-4648-0522-6_ch9
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Research Article

Improving water, sanitation, and hygiene (WASH), with a focus on hand hygiene, globally for community mitigation of COVID-19

Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Waterborne Disease Prevention Branch, Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America

Roles Data curation, Formal analysis, Methodology, Project administration, Writing – original draft, Writing – review & editing

Affiliation Emergency Response and Recovery Branch, Division of Global Health Protection, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America

Roles Data curation, Formal analysis, Funding acquisition, Methodology, Supervision, Writing – original draft, Writing – review & editing

Roles Data curation, Methodology, Writing – original draft, Writing – review & editing

Affiliation Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America

Roles Data curation, Formal analysis, Methodology, Writing – original draft, Writing – review & editing

Affiliations Waterborne Disease Prevention Branch, Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America, CDC Foundation, Atlanta, Georgia, United States of America

Roles Data curation, Methodology, Writing – review & editing

Roles Data curation, Formal analysis, Investigation, Validation, Writing – original draft, Writing – review & editing

Affiliations Waterborne Disease Prevention Branch, Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America, Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America

Roles Conceptualization, Funding acquisition, Supervision, Writing – review & editing

Roles Formal analysis, Investigation, Methodology, Writing – original draft, Writing – review & editing

Roles Data curation, Formal analysis, Supervision, Writing – review & editing

Affiliation Infectious Diseases Institute, Makerere University, Kampala, Uganda

Roles Data curation, Formal analysis, Methodology, Supervision, Writing – review & editing

Roles Data curation, Formal analysis, Investigation, Methodology, Writing – review & editing

Roles Project administration, Supervision, Writing – review & editing

Affiliation Safe Water and AIDS Project, Kisumu, Kenya

Roles Data curation, Formal analysis, Investigation, Methodology, Supervision, Writing – review & editing

Roles Data curation, Formal analysis, Investigation, Supervision, Writing – review & editing

Affiliation Washington State University, Nairobi, Kenya

Roles Project administration, Resources, Supervision, Writing – review & editing

Roles Data curation, Formal analysis, Project administration, Writing – review & editing

Affiliation Universidad del Valle de Guatemala, Guatemala City, Guatemala

Roles Data curation, Formal analysis, Methodology, Project administration, Supervision, Writing – review & editing

Affiliation Washington State University, Pullman, Washington, United States of America

Roles Investigation, Supervision, Writing – review & editing

Roles Writing – review & editing

Affiliation Epidemiology Department, Ministry of Health, Santo Domingo, Dominican Republic

Roles Data curation, Investigation, Supervision, Writing – review & editing

Affiliation Brigham and Women’s Hospital, Harvard University, Boston, Massachusetts, United States of America

Affiliation Department of Pediatrics, Division of Tropical Medicine, Baylor College of Medicine, Houston, Texas, United States of America

Roles Data curation, Formal analysis, Investigation, Writing – review & editing

Affiliations Department of Pediatrics, Division of Tropical Medicine, Baylor College of Medicine, Houston, Texas, United States of America, Belize Ministry of Health and Wellness, Belmopan, Belize

Affiliation Belize Ministry of Health and Wellness, Belmopan, Belize

Roles Data curation, Formal analysis, Project administration, Supervision, Writing – review & editing

Affiliation UNICEF, Kinshasa, Democratic Republic of Congo

Affiliation UNICEF, Ouagadougou, Burkina Faso

Roles Data curation, Formal analysis, Investigation, Project administration, Writing – review & editing

Roles Investigation, Project administration, Supervision, Writing – review & editing

Affiliation UNICEF, New York, New York, United States of America

Roles Data curation, Investigation, Project administration, Supervision, Writing – review & editing

Affiliation Department of Hygiene and Public Health, Ministry of Health, Kinshasa, Democratic Republic of Congo

Affiliation CARE Canada, Ottawa, Ontario, Canada

Affiliation CARE International in Uganda, Kampala, Uganda

Roles Project administration, Resources, Writing – review & editing

Affiliation Division of Global Health Protection, Centers for Disease Control and Prevention, Kampala, Uganda

Affiliation Division of Global Health Protection, Centers for Disease Control and Prevention, Nairobi, Kenya

Affiliation Division of Global Health Protection, Centers for Disease Control and Prevention, Guatemala City, Guatemala

•  [ ... ],

Roles Conceptualization, Investigation, Project administration, Resources, Supervision, Writing – original draft, Writing – review & editing

• [ view all ]
• [ view less ]
• David Berendes, 
• Andrea Martinsen, 
• Matthew Lozier, 
• Anu Rajasingham, 
• Alexandra Medley, 
• Taylor Osborne, 
• Victoria Trinies, 
• Ryan Schweitzer, 
• Graeme Prentice-Mott, 

• Published: June 15, 2022
• https://doi.org/10.1371/journal.pwat.0000027
• Reader Comments

Continuity of key water, sanitation, and hygiene (WASH) infrastructure and WASH practices—for example, hand hygiene—are among several critical community preventive and mitigation measures to reduce transmission of infectious diseases, including COVID-19 and other respiratory diseases. WASH guidance for COVID-19 prevention may combine existing WASH standards and new COVID-19 guidance. Many existing WASH tools can also be modified for targeted WASH assessments during the COVID-19 pandemic. We partnered with local organizations to develop and deploy tools to assess WASH conditions and practices and subsequently implement, monitor, and evaluate WASH interventions to mitigate COVID-19 in low- and middle-income countries in Latin America and the Caribbean and Africa, focusing on healthcare, community institution, and household settings and hand hygiene specifically. Employing mixed-methods assessments, we observed gaps in access to hand hygiene materials specifically despite most of those settings having access to improved, often onsite, water supplies. Across countries, adherence to hand hygiene among healthcare providers was about twice as high after patient contact compared to before patient contact. Poor or non-existent management of handwashing stations and alcohol-based hand rub (ABHR) was common, especially in community institutions. Markets and points of entry (internal or external border crossings) represent congregation spaces, critical for COVID-19 mitigation, where globally-recognized WASH standards are needed. Development, evaluation, deployment, and refinement of new and existing standards can help ensure WASH aspects of community mitigation efforts that remain accessible and functional to enable inclusive preventive behaviors.

Citation: Berendes D, Martinsen A, Lozier M, Rajasingham A, Medley A, Osborne T, et al. (2022) Improving water, sanitation, and hygiene (WASH), with a focus on hand hygiene, globally for community mitigation of COVID-19. PLOS Water 1(6): e0000027. https://doi.org/10.1371/journal.pwat.0000027

Editor: Silvia Monteiro, Universidade de Lisboa Instituto Superior Tecnico, PORTUGAL

Received: February 17, 2022; Accepted: May 21, 2022; Published: June 15, 2022

This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.

Data Availability: Data is available in Supporting Information S1 Data .

Funding: This work was funded through CDC cooperative agreements as part of emergency response to the COVID-19 pandemic (DB, MLo, JM, and TH received funding within CDC; AMwa, MLa, MKN, DC, KOM, PYO, OEH, AMat received funding on partner side-outside of CDC). The funders had no role in study design, data collection, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Introduction

As of November 5, 2021, there have been more than 248 million confirmed cases of coronavirus disease 2019 (COVID-19), of which almost 60 million (a conservative estimate) were in Southeast Asia, Africa, and the Western Pacific regions [ 1 ]. Multiple waves of COVID-19 cases continue to threaten low- and middle-income countries (LMICs) [ 2 ]. As of the same date, almost 8 billion doses of COVID-19 vaccines have been administered globally, though comparatively few in LMICs; less than 6% of people in low-income countries have received at least one dose of a COVID-19 vaccine [ 3 ]. International collaborative vaccination efforts, such as the COVID-19 Vaccines Global Access (COVAX) project, have procured and shipped 236 million doses to date [ 4 ]; however, goal levels for COVAX represent doses sufficient for only about 20% of those in LMICs. Reaching high vaccine coverage takes time in these populations: prevention and community mitigation measures to combat COVID-19—such as screening, isolation, quarantine, social distancing, masking, hand hygiene, and regular cleaning (with disinfection as-needed) of surfaces—remain critical to prevention and control of further waves of COVID-19 in LMICs [ 5 , 6 ].

Functional water, sanitation, and hygiene (WASH) infrastructure and consistent practice of key WASH behaviors are critical for prevention of respiratory and enteric infections [ 6 , 7 ]. Regular hand hygiene is a foundational, individually-actionable, and non-pharmaceutical strategy for combatting transmission of COVID-19 [ 8 , 9 ], whether through handwashing with soap and water or using an alcohol-based hand rub (ABHR) with at least 60% alcohol content. Sources, treatment, and storage of water in quantities sufficient for basic needs (drinking, washing hands) is essential, especially if an individual must isolate or quarantine after infection or recent exposure. Similarly, isolation or quarantine may require functional, well-managed sanitation facilities, including enhanced cleaning and disinfection measures for shared facilities [ 10 ].

COVID-19-focused community mitigation guidance for LMICs that incorporates WASH can be developed from existing WASH standards [ 7 ]. The Joint Monitoring Program (JMP) of the United Nations Children’s Fund (UNICEF) and the World Health Organization (WHO) have published normative criteria for water, sanitation, and hygiene ladders whose “basic” or “safely-managed” criteria can act as minimum standards for WASH access in households [ 11 ], schools [ 12 ], and healthcare facilities (HCFs) [ 13 ]. In humanitarian emergencies, Sphere guidance includes minimum standards for core WASH services that may apply to the COVID-19 pandemic, including minimum water quantities for drinking and personal use (e.g., hygiene) and standards for hygiene promotion and hygiene items [ 14 ]. For displaced populations, the United Nations High Commissioner for Refugees (UNHCR) has identified critical WASH practices to prevent the spread of COVID-19 in refugee locations with high population density and shared WASH services [ 15 ].

Before the pandemic, access to essential WASH services in LMICs was poor. Worldwide, 60% of households and 53% of schools had basic hygiene, defined as a handwashing station (HWS) with soap and water, but for United Nations-categorized least developed countries (LDCs), only 28% of households and 26% of schools had this infrastructure [ 11 , 16 , 17 ]. About 74% of HCFs in LDCs had hand hygiene at points of care [ 18 , 19 ]. Although water quantity is not directly measured, 74% of households globally—but only 37% in LDCs—had onsite water sources available when needed [ 11 ]. Onsite water sources were present in 74% of HCFs and 69% of schools globally, but only 50% and 53%, respectively, in LDCs [ 12 , 13 ]. Private (unshared) sanitation (categorized as at least basic sanitation) at households was 78% globally, but only 37% in LDCs [ 11 ]. According to publicly-available data from UNHCR, in 119 sites that submitted data in March 2020, only 34% of refugee households had access to private sanitation; most sanitation facilities were shared (median: 14 people per facility) [ 20 ].

The COVID-19 pandemic adds new considerations to deploying and managing WASH in LMICs ( Table 1 ). For example, hand hygiene technologies—ABHR, handwashing with soap and water, soapy water, or use of chlorinated water—each present benefits but also challenges to ensuring quality control, use at appropriate times, user acceptability, and feasibility of maintenance under high-use conditions. Although there is no evidence to date that SARS-CoV-2 is transmitted through water or feces [ 21 , 22 ], public water sources and sanitation facilities may require additional COVID-19 mitigation measures to reduce crowding and ensure frequently-touched surfaces are cleaned regularly. Increased and competing demand for water for hygiene may also challenge water availability at public sources and storage capacity at households.

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https://doi.org/10.1371/journal.pwat.0000027.t001

Combining existing WASH guidance with community mitigation guidance for COVID-19, we partnered with organizations and governments in LMICs in Latin America and the Caribbean (LAC) and Africa to assess WASH conditions and practices and deploy and manage WASH interventions to mitigate COVID-19. We focused assessments and interventions by setting (HCFs, community institutions, and households), primarily focused on hand hygiene initially. Results from these and other evaluations will strengthen the evidence base for WASH mitigation measures for COVID-19 in LMIC settings and identify new challenges or persisting gaps where further improvements are needed. By building partner capacity to conduct mixed-methods monitoring and evaluation, these projects may also improve sustainability of WASH services.

Selection of locations and assessment approach

Countries were prioritized based on existing partnerships, CDC country office collaboration, and anticipated risk of COVID-19 transmission and consequences based on existing country resources. Within countries, HCFs were selected by governmental and non-governmental partners based on risk for COVID-19 transmission, program viability, and in-country partner presence. Community institutions that were perceived to be high risk for COVID-19 transmission (e.g., had population mixing in densely-populated areas) were prioritized based on country partner or governmental guidance. In districts or regions with international borders or points of entry (POE), and therefore highly mobile populations, the CDC Population Connectivity Across Borders (PopCAB) toolkit [ 23 ] helped identify priority community settings associated with mobile populations, including additional POE and checkpoints, schools, markets, and other priority non-HCF community institutions. Household-level assessments were prioritized through partnerships with organizations that had existing health- or WASH-focused programs in low-resource locations of high-COVID-19 transmission risk, for example densely-populated informal settlements and internally displaced persons (IDP) camps. For all settings, priority locations selected and methods used varied slightly by the population served (e.g., refugee, IDP population, or general community). All settings (HCFs, community institutions, households) underwent WASH assessments and collection of qualitative data [focus group discussions (FGDs) or key informant interviews (KIIs)]; methods in HCF and community institutions were similar because new tools required for community institutions were generally derived from HCF-specific tools ( Table 2 ).

https://doi.org/10.1371/journal.pwat.0000027.t002

Quantitative: WASH assessments, knowledge, attitudes, and practice surveys, hand hygiene observations

Where feasible, baseline assessments of WASH conditions used existing tools for assessing WASH in the given setting that were modified to focus on hand hygiene needs for COVID-19. In HCFs, tools included the water and sanitation for health facility improvement tool (WASH FIT), which identifies WASH gaps in HCFs and prioritizes interventions using national and international standards and can be used on a continuous cycle of improvement by facility staff [ 24 ]. A second tool was the CDC assessment form for HCFs, which focuses on facility services and staff, water supply, sanitation, and hand hygiene resources (appropriate hand hygiene technologies present: ABHR or handwashing stations with soap and water for HCFs specifically [ 22 ]) at points-of-care [ 25 ]. In community institutions, WASH assessments were adapted from HCF-specific tools to target water supply and hand hygiene resources (appropriate hand hygiene technologies present: ABHR, handwashing stations with soap and water, or chlorinated water solutions [only when the other technologies were not available) for community locations [ 22 ]) at location entrances and exits [prioritized for hand hygiene by WHO during COVID-19 pandemic [ 26 ]] and outside toilets. For households, WASH assessments were adapted from JMP questions to assess household hygiene and water ladders [ 11 ] and knowledge, attitudes, and practices (KAP) survey questions were adapted from existing CDC and partner WASH KAP tools with an increased emphasis on handwashing and water access. Questions were added to household WASH and KAP assessment tools on knowledge of COVID-19 prevention and perceptions of local response and mitigation measures. WASH assessments were conducted in all HCFs, community institutions, and households selected. KAP surveys were conducted in all households selected.

Hand hygiene observations were conducted in HCFs and community institutions. In HCFs, observers followed a single provider for three to five patient encounters and noted whether hand hygiene was performed (and the technology used, if performed) before and after patient contact as described for those moments in WHO hand hygiene observation guidance [ 27 ]. To minimize bias, observers were introduced as observing quality of patient-provider care interactions (similar to structured observations using a mystery shopper method [ 28 ]) or as observing general hygiene practices (Guatemala). In community institutions, hand hygiene observations were conducted at locations where hand hygiene materials were present and expected to be used: location entrances and exits and outside latrines [ 26 ]. Similar to HCFs, practicing/not practicing hand hygiene and the technology used were noted, along with the approximate age of the participant (child, adolescent, adult) to target future messaging. In HCFs, a goal of 3–5 patient contacts for each of 90 providers in HCFs per site (generally 3–5 providers at each HCF in a site). If the goal number of patient contacts could not be attained after 30 minutes following a given provider, the observer was instructed to move on to the next provider at that HCF. In community institutions, observers stood in an inconspicuous location, as far away from a given hand hygiene station as possible while still being able to observe it, and randomly observed someone entering/exiting the facility or a random latrine known to be in use and visually followed the individual until either they had performed hand hygiene or passed by the hand hygiene station, whichever came first. For these observations, approximately half of available locations (e.g. individual markets, POE) were selected for hand hygiene observations with a goal of observing a total of 20 hand hygiene events per location. Hand hygiene observations were in locations not serving IDPs or refugee populations.

Qualitative: Focus Group Discussions (FGDs), Key Informant Interviews (KIIs)

Qualitative data—whether collected by FGDs or KIIs—were collected in all settings with differing target participants ( Table 2 ). In most HCFs, FGDs were originally planned, but due to social distancing concerns and limits on the number of individuals in a single space, KIIs usually replaced FGDs (though FGDs were successfully conducted in Belize). KIIs were conducted with healthcare providers, maintenance staff, and administrators to assess behavioral motivators and barriers to practicing hand hygiene before and after patient contact and challenges to managing hand hygiene at the facility. In community institutions, KIIs were conducted with staff and managers to understand barriers and motivators to hand hygiene in that setting and any existing management structures for hand hygiene, if they existed. FGDs were conducted separately with vendors and shoppers at markets to assess challenges to hand hygiene adherence. In households, FGDs were conducted with recipients of handwashing stations and hygiene kits and community volunteers to assess motivators and barriers to hand hygiene. Qualitative tools used in community institutions and households were designed from those used in HCFs. In general, KIIs were conducted at 50% of targeted HCFs and community locations. FGDs in markets were set at five for vendors and five for shoppers.

Schematics.

Schematics were a methodology used in community institutions, but not HCFs or households. Facilitators helped location managers to create drawings showing key locations where hand hygiene should be placed (e.g., entrances/exits, latrines, vendors, public gathering or eating locations), which was subsequently used to identify current hand hygiene resources and future needs.

Guidance for interventions.

Interventions were initiated after—and based on—baseline WASH assessments. Areas of intervention can be found in Table 3 . The guidance used or developed for the specific interventions settings is listed below:

https://doi.org/10.1371/journal.pwat.0000027.t003

HCFs . JMP service ladders and concurrent normative WASH guidance exist for HCFs as of 2017 [ 13 ]. Additionally, WHO guidance describes WASH-related practices that are important for mitigating the spread of SARS-CoV-2 in HCFs, including engaging in frequent and proper handwashing with soap and water or use of ABHR, implementing regular environmental cleaning and disinfection practices, managing excreta safely, and safely managing healthcare waste produced by COVID-19 cases [ 22 ].

Community institutions . Schools are the only community institution where normative WASH assessments exist via JMP-established service ladders [ 12 ]. In POE, although governments may provide guidance for national POE, there are no global recommendations for WASH at POE. In 2020, CDC, the WHO and other organizations developed operational considerations and recommendations for COVID-19 mitigation in community institutions in LMIC settings, including markets, schools, humanitarian settings, and high-density urban areas [ 10 , 29 – 36 ]. These recommendations were based on existing CDC and partner guidance where available (e.g., USAID guidance for safe and functioning food markets; WHO guidance for disinfecting environmental surfaces) and emphasized the importance of increasing access to hand hygiene and enhancing environmental cleaning and other control measures in high-use areas such as shared toilets.

Household . Following existing normative WASH standards, ensuring access to at least basic hygiene infrastructure (handwashing materials on premise with both water and soap) is an important global hygiene standard [ 11 , 16 ]. Guidance on behavioral messaging focused on key times to practice hand hygiene both generally (e.g., after the toilet, before eating, after coughing or sneezing or blowing one’s nose) [ 9 ] and during the pandemic (e.g., after being in public spaces) [ 8 , 37 ].

Broadly, the WASH assessments conducted and presented in this manuscript were exempt from formal institutional review board (IRB) approvals in Uganda, Kenya, Guatemala, Burkina Faso, and the Democratic Republic of the Congo because they were part of ongoing emergency public health response measures by CDC and local partners to the COVID-19 pandemic. Data collection in Belize and the Dominican Republic required IRB review given it was nested within ongoing data collection efforts. In Belize, protocols for data collection were approved by Baylor College of Medicine and the Belize Ministry of Health and Wellness. In the Dominican Republic, protocols for data collection were approved by the National Council of Bioethics in Health, Santo Domingo; the IRB of Pedro Henriquez Urena National University, Santo Domingo; and Mass General Brigham Human Research Committee, Boston, USA. No deviations to protocols occurred after approvals. Verbal or written informed consent (as suggested by the local partner or review board based on cultural acceptability and other factors) was obtained from healthcare workers prior to observations. Additional information regarding ethical, cultural, and scientific considerations to inclusivity in global research is included in S1 Text . All data are available in S1 Data .

Results, interventions, and monitoring and evaluation

Healthcare facilities.

WASH baseline assessments have been conducted at 114 HCFs across six countries ( Table 4 ) and observations of healthcare providers at 54 HCFs in five countries ( Table 5 ). HCF assessments have been completed in Belize (all government-supported hospitals and several priority outpatient clinics), Burkina Faso (Centre Nord and Est Regions, which served internally-displaced persons; HCFs prioritized by UNICEF and Ministry of Health), Dominican Republic (two large hospitals not in Santo Domingo: HCFs prioritized through participation in an acute febrile illness surveillance system to ensure geographic coverage and logistical feasibility of intervention delivery), Guatemala (five municipalities within Quetzaltenango Department: HCFs prioritized through participation in an acute febrile illness surveillance system to ensure geographic coverage and logistical feasibility of intervention delivery), Kenya (Nyando and Nyakach sub-counties in Kisumu County: all HCFs prioritized due to existing partner collaborations and displacement and concurrent flooding risks), and Uganda (community/non-refugee or IDP populations: Amuru and Tororo Districts: HCFs prioritized among non-refugee/IDP populations via PopCAB assessment; refugee/IDP populations: Adjumani, Arua, Madi-Okollo, and Terego Districts: HCFs prioritized by Ministry of Health, UNHCR, and local WASH partners).

https://doi.org/10.1371/journal.pwat.0000027.t004

https://doi.org/10.1371/journal.pwat.0000027.t005

HCF infrastructure.

Most HCFs had access to an onsite, improved water supply (100% of HCFs in Belize, Dominican Republic, and Kenya program sites, 95% in Guatemala sites, 80% in Uganda sites, 66% in Burkina Faso sites, Table 4 ). However, hand hygiene resources at points-of-care were less prevalent: two HCFs surveyed in Belize (18%), three HCFs in Uganda (25% of those surveyed in non-refugee/IDP populations), and two HCFs in Kenya (5%) had access to hand hygiene resources at all points-of-care. All HCFs assessed in Guatemala had hand hygiene resources at 75–99% of points-of-care; 47% in Burkina Faso, 46% in Belize, 33% in Uganda (non-refugee/IDP), 31% in Uganda (refugee/IDP), 5% in Kenya, and 0% in Dominican Republic met this criterion.

HCF hand hygiene adherence.

Healthcare providers in participating HCFs had moderate to low levels of hand hygiene adherence around patient contact (49% in Belize, 38% in Uganda, 30% in Guatemala, <25% each in Dominican Republic and Kenya, Table 5 ). In all sites, providers practiced hand hygiene more frequently after patient care (range: 25–62% by site) than they did before patient care (9–39%).

Interventions.

In all HCFs, interventions included HWS or ABHR at points-of-care and entrances and exits [ 26 ], and HWS at toilets ( Table 3 ), with an objective of 100% coverage per HCF. In HCFs serving refugee populations and IDPs, interventions also included distribution of environmental cleaning and hygiene kits (via antenatal clinics), as well as hygiene promotion sessions and trainings on COVID-19 prevention for health facility staff and patients. In HCFs serving general populations, partners implemented ABHR programs using the WHO Guide to Local Production of ABHR [ 38 ] to train local technicians in production and distribution models specific to their facility, district, or national needs. Findings from qualitative baseline assessments are also being used to develop behavior change interventions in HCFs.

Monitoring and evaluation.

To measure the feasibility, acceptability, use, and sustainability of interventions, monitoring and evaluation tools were developed from baseline assessments. Tools focused on monitoring functionality, availability of soap and water, and water quality at HWS; quantity and quality of ABHR at production facilities; and functionality of dispensers and levels of ABHR consumption by HCFs. Hand hygiene observations will be repeated periodically, with data shared with HCF leadership to provide a feedback loop to inform further trainings and encourage improved hand hygiene adherence. Similarly, repeat assessments will be conducted for water storage capacity and environmental cleaning supply quantities.

Community institutions

To-date, WASH assessments of community institutions have been conducted in Uganda (10 markets, 15 POE, 7 schools) and DRC (27 schools, Table 6 ). Hand hygiene observations have been conducted at all community institutions in Uganda, as well as five vendor- and five shopper-focused FGDs and 16 KIIs. Community institution assessments have been completed in Uganda (Amuru and Tororo Districts) and the DRC (North Kivu and Kasai-Central provinces). In Uganda, schools, POE, lodging locations, markets, and religious institutions were identified via the PopCAB assessment as priority locations with high population mixing in Amuru and Tororo Districts. In the DRC, schools were selected in Goma and Kananga to complement ongoing CDC work on cholera and in key areas identified for COVID-19 mitigation.

https://doi.org/10.1371/journal.pwat.0000027.t006

Markets in Uganda had poor access to water (44% had an improved water source onsite) and HWS (50% had any HWS, Table 6 ). Observed hand hygiene at key times was moderate and better than other community settings observed: 58% of people entering/exiting markets were observed to clean their hands and 63% of people cleaned their hands after using the latrine ( Table 7 ).

https://doi.org/10.1371/journal.pwat.0000027.t007

KIIs with market managers in Uganda revealed support for both HWS (for vendors and visitors whose hands get heavily soiled) and ABHR (for speed and convenience) onsite and suggested that hand hygiene should be enforced by a monitor at market entrances. Managers felt staff and customers would need education on effective hand hygiene and suggested using posters with strong visual aids.

FGDs among vendors and shoppers found that hand hygiene stations at entrances/exits, though considered essential, were not easily accessible for vendors. Additional stations within the market were recommended to improve access. Additionally, most HWS installed in the early months of the pandemic were no longer functioning due to lack of management plans or identified responsibilities. Both vendors and shoppers believed that hand hygiene was effective for preventing COVID-19 and were motivated to practice hand hygiene to protect themselves, their children, and friends from disease, as well as to feel and appear clean.

Many, but not all, POE had access to an improved water source onsite (71%) and HWS (60%), including at entrances and exits (71%, Table 6 ). However, only 19% of people entering or exiting the POE cleaned their hands and only 42% of people cleaned hands after using the latrine ( Table 7 ).

Based on KIIs, ABHR was identified as a more convenient method for hand hygiene due to the high volume of travelers and number of contact events between POE staff and travelers. However, poor access to and high cost of ABHR, as well as the layout of some POE, challenged consistent access to hand hygiene for staff and travelers. Although some POE received ABHR from local HCF, increasing and sustaining ABHR access and improving access to HWS was viewed as a critical priority.

In Uganda, all schools had access to an improved water supply onsite (100%) and most had handwashing stations (86%), including at entrances/exits (71%, Table 6 ). In DRC, although 67% of schools had either temporary or permanent HWS, only 30% had an improved water source available on the premises ( Table 6 ).

Observed hand hygiene adherence was poor in schools in Uganda: 17% of students or staff entering/exiting the school were observed to clean their hands and only 39% were observed to clean hands after using the latrine ( Table 7 ).

Based on data from KIIs in Uganda, head teachers felt that it would be best for students to use HWS but that ABHR would be good for visitors and teachers, and particularly for head teachers since they interact with many visitors. ABHR was prohibited from use by children in schools in Kenya by the Ministry of Education due to concerns over their ability to safely and appropriately use it [ 39 ].

Market and POE interventions focus on improving access to HWS and locally-produced ABHR, as well as hygiene education materials, at key locations (entrances and exits and outside latrines) for staff or visitors ( Table 3 ). Amount of hand hygiene resources required for staff and travelers will vary based on the location size, existing infrastructure or layout, and local regulations. School interventions will focus on ensuring access to hand hygiene at entrances, exits, within classrooms, and within 5 meters of toilets/latrines; hand hygiene promotion; and ensuring sufficient water supply for increased hand hygiene and cleaning needs.

Monitoring will focus on functionality of hand hygiene stations (including resources available, usability, and water quality) and ABHR quality and use (where present; Table 3 ). Periodic evaluations will include intercept interviews with users to assess acceptability of hand hygiene, KIIs and FGDs with staff or managers to assess feasibility of management, observations to assess use, water quality testing of free chlorine residual, and targeted evaluations assessing appropriateness of use cases for ABHR in communities. Tools used will be adapted from baseline assessments.

To-date, household WASH assessments and KAP surveys have been conducted at 405 households in Burkina Faso ( Table 6 ). Assessments have been completed in households in areas prioritized by the Ministry of Health in Burkina Faso (Diabo Commune, Est Region; Boroum Commune, Centre Nord Region).

Access to WASH at household level.

Almost all households (96%) in sites in Burkina Faso used water from an improved source; however, few (2%) had a handwashing station present ( Table 6 ).

Household reported hygiene knowledge, motivators, and barriers.

In sites in Burkina Faso, 49% (199/405 household surveyed) reported using water only (no soap) during regular handwashing. In Kenyan informal settlements, FGD participants highlighted that placement of HWS near a doorway served as a reminder to wash hands, but this benefit may not exist where HWS are shared among several households. In such cases, disrepair or abandonment might occur due to perceptions of diminished responsibility. FGD participants discussed the need for inter-household agreements to rotate costs of supplying water and soap.

Initial interventions—freestanding, temporary HWS in high traffic areas to maximize the number of households reached per HWS—quickly broke down due to misuse, damage, or theft because resources for full-time operators were not available. Interventions subsequently shifted to household- or compound (groups of households sharing a space)-level HWS. Objectives were to achieve access to at least basic hygiene in households or compounds; to identify barriers, motivators, and gaps to hand hygiene adherence in communities for message development and dissemination; and to monitor utilization and sustainability of approaches to hand hygiene access and messaging. Households received hand hygiene kits (e.g., HWS, 20-L water storage containers, and bars of soap) complemented by awareness campaigns organized with local community health workers to improve knowledge of COVID-19 mitigation measures. In some contexts, hygiene kits were distributed through maternal, newborn and child health activities in HCFs: expectant mothers received a hygiene kit plus face masks, ABHR, and communications materials at their first prenatal visit. Community health workers subsequently provided hygiene promotion messages during prenatal household visits.

To sustain interventions, periodic monitoring and evaluation will be conducted via repeat visits or text/phone-based assessments of functionality of HWS and interviews about acceptability and feasibility of HWS designs and maintenance ( Table 3 ). Tools were adapted from baseline assessments with additional questions focusing on barriers to maintaining hand hygiene stations and adherence.

Discussion, future directions, challenges and limitations, and conclusions

The need for at least basic levels of WASH in HCFs, community institutions, and households has only increased during the COVID-19 pandemic. The focus on WASH in HCF just before 2020, accompanied by existing guidance and standards for WASH in schools and households, provided multiple appropriate WASH assessment tools that could be readily adapted for COVID-19-focused assessments. However, in other community institutions such as markets or POE, CDC and WHO created new operational guidance based on existing WASH guidance for other settings and added COVID-19-specific considerations.

Data from baseline assessments conducted to-date demonstrate poor access to hand hygiene resources at key public locations—points-of-care in HCFs, entrances/exits and at toilets in community institutions—despite most, except schools in DRC and markets in Uganda, having access to an improved, onsite water supply. Other enabling factors for hand hygiene, such as sufficient water quantity and management plans for restocking supplies and repairing HWS, may need to be prioritized. Local ABHR production may be a cost-effective complement to HWS in appropriate settings and projects are currently scaling the WHO protocol [ 38 ] to district, regional, and national levels in five countries.

Where hand hygiene resources were available, healthcare providers and community members had low adherence overall. Healthcare providers were more likely to clean hands after than before patient contact, suggesting that behavioral interventions to improve compliance should increase emphasis on protecting the patient in addition to protecting oneself. Hand hygiene in healthcare contexts requires a multimodal approach, including systems-level change to improve access to hand hygiene materials but also training and education, monitoring of practices, reminders and nudges, and establishment of a culture to reinforce practices [ 40 – 42 ]. Community members were more likely to clean hands after the toilet than at entrances/exits, suggesting a need for greater communication of other key times to wash hands, especially during the pandemic [ 22 , 26 , 37 ]. However, models such as the Integrated Behavioral Model for WASH (IBM-WASH) suggest that multiple levels, beyond the individual, should be considered in uptake of WASH behaviors: these include societal, community, interpersonal, and habitual levels [ 43 , 44 ]. For example, the context of the pandemic itself may factor into the drivers of hand hygiene uptake, but these behaviors need to be matched to the appropriate technology as well. Further research into methods to prolong outbreak-associated (short-term) behavior change is needed, though evidence suggests that awareness/knowledge-based methods may have limited effect if not addressing multiple societal levels [ 43 – 47 ].

Similar to community and HCF locations, household use of improved water sources was high but access to HWS was poor. HWS targeted to multiple households—via shared or otherwise freestanding community infrastructure—suggest cost-efficient ways to temporarily increase community coverage; however, the absence of management considerations may cause infrastructure to become unusable. Community HWS attached to retail points, schools, and other community institutions can help improve responsible management; however, household- or compound-focused interventions may be more feasible, manageable, and help achieve basic hygiene access for longer term prevention capacity [ 16 ].

Future directions

The new WASH-focused guidance necessitated by the COVID-19 pandemic—including guidance for public places: placement, management, and behavior change communication about hand hygiene in markets, POE, and other community institutions, and who is responsible for these aspects—must be implemented, monitored, evaluated, and improved to maximize feasibility and acceptability while maintaining effectiveness. Though human rights to accessing WASH services in public places has been emphasized by the United Nations General Council [ 48 ] and individual nations may have guidance, systematic, global guidance for WASH standards in public places is a gap. The microbiological quality of water for handwashing is not currently incorporated into the hygiene ladder [ 16 ] and thus is an area of new guidance. Although limited evidence suggests that non-potable water with low-to-moderate E . coli contamination still may be effective when used for handwashing [ 49 ], the potential for dual-use of water from handwashing stations being consumed because of limited access to basic and safely-managed water services [ 11 ] suggests that potable levels of water quality may be necessary in many areas. Within our sites, water for handwashing will be tested at the source and at the handwashing station for free residual chlorine (except if only soapy water for handwashing is present, as this may affect accuracy of chlorine residual measurements). If free residual chlorine levels are <0.2mg/L, an additional sample will be collected for assessment of presence or absence of fecal indicator bacteria.

Sanitation management—for example, development of standard operating procedures (SOPs) to clean and manage public toilets in densely-populated locations and improvement of personal protective equipment (PPE) use by manual pit emptiers to protect themselves and their customers while entering households—should be prioritized as essential services [ 7 ]. Access to public toilets may be the only means of sanitation access for many globally, and should be managed so as to avoid added risk from communal spaces [ 7 ], with similar arguments for improving the hygienic practices of pit emptiers. SOPs for public facilities have often focused on managing fecal waste, but improvements to cleaning and disinfection guidance, social distancing while queuing, and other changes may be necessitated.

ABHR is an effective complement to HWS in HCFs and has logistical and financial savings if produced locally; however, appropriate supply chains for and appropriate use in community settings must be evaluated. In community settings, CDC recommends ABHR when handwashing with water and soap are not practically available [ 9 ] because soap and water may be more effective at removing a broader array of microbes, as well as other unknown chemical or organic materials, that may be present on hands [ 50 ]. Furthermore, ABHR is effective against microbes specifically, but is less likely to effectively inactivate them if hands are visibly dirty [ 51 ]. Before expanding ABHR in these settings in the short to medium term, evaluations should ensure targeted community settings are appropriate for use of ABHR, with concurrent messaging if necessary to guide users on when to use soap and water vs. ABHR.

In our program sites, access to ABHR in community institutions does not have clear supply chains. In previous work in Uganda, locally-produced ABHR at POE followed HCF supply chains because of Ebola preparedness efforts, but markets, schools, or other key community locations were not included. To ensure sustainable access to ABHR in LMICs, there is a need to evaluate whether HCF-based local production and distribution to non-HCF locations is feasible or if non-HCF-based production and distribution models are needed.

Challenges and limitations

Sustaining hand hygiene behavior change remains the largest challenge to-date, requiring consistent access to functional hand hygiene stations at key locations, behavioral nudges or reminders to perform hand hygiene at key moments, and local, regional, and national support for hand hygiene integrated across programs [ 16 ]. Installation of hand hygiene facilities must include plans for their management and repair, including identifying supplies and repair parts and personnel responsibilities for restocking, cleaning, maintenance, and repair [ 52 ]. As in many outbreak situations, rapid deployment of HWS in project sites without concurrent maintenance plans led those stations to quickly deteriorate or become unusable within a year despite longer advertised lifespans [ 53 ], which wastes resources and reduces access to hand hygiene. Lack of consistent access to hand hygiene resources may inhibit changes to behavior and development of hand hygiene as a habit [ 47 , 54 ]. To ensure sustained hand hygiene access and behavior change, support must come from multiple disciplines (e.g., healthcare, education, WASH partners, community) integrating hand hygiene into new and existing work plans, rather than isolated or temporary initiatives [ 16 ].

There are several limitations to consider within the context of these assessments and guidance. Notably, data are site- and context-specific and may not be generalizable to other settings. Although inclusiveness of WASH services by persons with disabilities are priorities for the WASH SDGs, including design of HWS [ 16 ], and are being accounted for in design of interventions, they were consistently not enumerated in baseline assessments. Additionally, WASH interventions are one of many tools, including masking, social distancing, and vaccination, that should be implemented for comprehensive community mitigation of COVID-19.

Conclusions

Within the COVID-19 pandemic, hand hygiene, water supply, and sanitation—all core components of WASH—have greater importance. In LMICs, we adapted common WASH tools for COVID-19 mitigation via rapid, mixed-methods assessments and adapted WASH guidance for settings without existing WASH standards (e.g., community markets, POE), with a focus on hand hygiene initially. We found inadequate hand hygiene access and behavioral adherence across LMIC contexts and settings—HCFs, community institutions, and households—and a need to improve personal and community capacity to follow guidelines for COVID-19 mitigation. These changes may include a need for greater water supply (for handwashing) and improved management of public sanitation facilities. Management of hand hygiene stations represents an area of elevated importance within the ongoing pandemic, for example, keeping HWS functional and well-stocked and ensuring continuous access to ABHR where available. New evaluation of these areas, and subsequent development and refinement of standards and assessment tools, will help ensure that WASH aspects of community mitigation of COVID-19 are accessible, functional, and usable for all.

Supporting information

S1 text. inclusivity in global health questionnaire (checklist)..

https://doi.org/10.1371/journal.pwat.0000027.s001

S1 Data. Data for manuscript.

https://doi.org/10.1371/journal.pwat.0000027.s002

Acknowledgments

The authors wish to acknowledge the efforts of all local implementation and evaluation partner staff, CDC country office staff, Ministries of Health, and participants.

Disclaimer: The findings and conclusions of this paper are those of the authors and do not necessarily represent the official position of the US Centers for Disease Control and Prevention (CDC).

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WASH (Water, Sanitation & Hygiene) and COVID-19

Coronavirus (COVID-19): Protect Yourself and Others

Safely managed water, sanitation, and hygiene (WASH) services are an essential part of preventing and protecting human health during infectious disease outbreaks, including the current COVID-19 pandemic. One of the most cost-effective strategies for increasing pandemic preparedness, especially in resource-constrained settings, is investing in core public health infrastructure, including water and sanitation systems. Good WASH and waste management practices, that are consistently applied, serve as barriers to human-to-human transmission of the COVID-19 virus in homes, communities, health care facilities, schools, and other public spaces. 

Safely managed WASH services are also critical during the recovery phase of a disease outbreak to mitigate secondary impacts on community livelihoods and wellbeing. These secondary impacts—which could include disruptions to supply chains, inability to pay bills, or panic-buying—have negative impacts on the continuity and quality of water and sanitation services, the ability of affected households to access and pay for WASH services and products (for instance, soap, point of use water treatment or menstrual hygiene products) and the ability of schools, workplaces and other public spaces to maintain effective hygiene protocols when they re-open. If not managed, secondary impacts can increase the risk of further spreading water borne diseases, including potential disease outbreaks such as cholera, particularly where the disease is endemic. 

According to a WHO/UNICEF technical brief on WASH and waste management for COVID-19:

Frequent and proper hand hygiene is one of the most important measures that can be used to prevent infection with the COVID-19 virus. WASH services should enable more frequent and regular hand hygiene by improving facilities and using proven behavior change techniques. 

WHO guidance on the safe management of drinking water and sanitation services applies to the COVID-19 outbreak. Measures that go above and beyond these recommendations are not needed. 

Many co-benefits will be realized by safely managing WASH services and applying good hygiene practices. Such efforts will prevent other infectious diseases, which cause millions of deaths each year.

Beyond the human tragedy, devastating economics impacts are anticipated in all countries and for the most vulnerable and marginalized people in society. Human and economic costs are likely to be larger for Fragile, Conflict, and Violence (FCV)-affected countries and lower and middle-income countries, that generally have limited coverage and capacity of water supply and sanitation systems, lower health care capacity, larger informal sectors, shallower financial markets, limited fiscal space, and poorer governance. As such, for all interventions it will be especially important to target FCV-affected countries—home to about two-thirds of the world’s extreme poor. While it is too early and with too many variables to quantify the economic costs of the pandemic, the costs of inaction would be catastrophic. 

Priority Areas

Action in the WASH sector is therefore critical for both containing the virus and lowering its immediate impact and aftermath. Three priority areas are identified as part of the emergency response:

Emergency support to secure and extend water and sanitation service provision, including:

• Support to water supply and sanitation (WSS) service providers to prepare emergency plans and ensure continuity of service delivery through inter alia: provision of water treatment chemicals and spare parts, availability of fuel for pumps and treatment, maintaining staffing levels, providing protective equipment for utility staff and salary supplements to compensate for the additional work-loads.

WASH Interventions for An Effective COVID-19 Pandemic Response

To respond to the COVID-19 pandemic, the World Bank Water Global Practice has developed a menu of solutions, including concrete actions to help our client governments in their preparedness and emergency response, and future resilience to similar epidemics. 

Preparedness and emergency response: Support affected, at-risk and low-capacity countries to secure Infection Prevention and Control (IPC) in health facilities and communities. 

Safe water supply, sanitation and hygiene services and medical waste management in health care facilities are essential to deliver quality health services, protect patients, health workers and staff, and to prevent further transmission. During an infectious disease outbreak, services should meet minimum quality standards and be separated for infected vs. non-infected patients. Support is required to ensure that services are not disrupted and products such as soap and alcohol-based hand rubs are available. Temporary health care facilities and quarantine sites also need to provide these services.  

Communication and preparedness related to handwashing behavior change and promotion, food hygiene and safe water practices. Materials for handwashing and hygiene may include the provision of fixed and portable handwashing facilities, purchasing of soap and alcohol-based hand rubs, provision of water supplies for handwashing and point of use water treatment. Schools, workplaces, markets, transport stations and other areas where people gather all require easy access to water and soap for handwashing. Proven behavior change techniques can help increase the frequency and improve the practice of critical hygiene behaviors. Resources such as the  Global Handwashing Partnership  can be tapped to mobilize private, public and civil society actors to support the development of messaging and materials to respond to COVID-19 outbreaks in various countries.  

Rapid, low-cost water service provision for communities, health care facilities and schools that currently lack access to a reliable and safe water supply is critical to enable handwashing, hygiene and disinfection. Providing quick, just-in-time community water access points/water kiosks (potentially including provision of soap) in unserved urban and rural areas, and for unserved health care facilities and schools. This would include: (i) provision and operation of compact water treatment plants; (ii) construction and operation of water points to deliver water in strategic urban or rural points; (iii) provision and operation of trucks for water delivery (bottled, sachets) and water tankers, including adequate water storage to service operators.  

Emergency support to water and sanitation utilities to ensure the continuity of water supplies, enhanced monitoring, staffing levels and spare parts. Additional emergency measures include ensuring that water utility staff have protective equipment, priority for testing, and salary supplements to compensate for the additional workload and risk. 

Emergency response to Fragility, Conflict, and Violence countries: The main principle of an emergency WASH response is to ensure the consideration of water supply, sanitation and hygiene factors at the site selection and planning stages, while also coordinating the response closely with physical planning, public health and environmental stakeholders.  The response must adhere to the multi-sectoral needs assessment for refugee emergencies (NARE), followed by a more detailed initial WASH rapid assessment of local WASH-related resources in relation to the need/demand.2 This includes an assessment of water resources (quantity and quality) for water sources and distribution options. 

Mitigating secondary impacts: WASH services and products are essential for well-functioning health care facilities and to avoid disrupting community livelihoods and wellbeing.  

Financial support to water and sanitation utilities to monitor and support cash reserves, the availability of water and wastewater treatment chemicals, the availability of electricity fuel for pumping and treating water, staffing levels and routine/capital maintenance. 

Providing technical assistance to governments to strengthen country systems including: (i) ‘agile’ service delivery mechanisms that may turn to local private sector entities to deliver safe water through ‘turnkey’ solutions under design-build-operate (DBO) contracts; (ii) enhanced water quality assurance/monitoring; (iii) preparation of utility emergency plans (absenteeism may be a serious risk); (iv) safely managing wastewater and fecal sludge; (v) emptying latrines and safely disposing excreta; (vi) monitoring secondary impacts. 

Financial support to beneficiaries to ensure the continuity of WASH services including financing for fee waivers to mitigate service disruption for households and institutions (schools, health care centers, government agencies, etc.). Ensure funding for WASH services and related products (soap, etc.) are included in Social Protection operations targeting poorer households. In fragile countries that lack social safety nets and wherein fiduciary arrangements do not allow for DPOs, in-kind distributions to vulnerable populations identified as most at risk (e.g. distribution hygiene and cleaning kits, water distribution, etc.). 

Ensuring the viability of critical supply chains such as for hygiene product availability in markets (e.g. soap, disinfectant, point of use water treatment supplies etc.), as well as import/export restrictions on critical equipment needed by utilities or households. 

Building resilience against future diseases: Safely managed WASH services are needed to support affected, at-risk, and low-capacity countries to build resilience against future pandemics, as well as against diseases that afflict the poor in the developing world on a more routine basis, such as diarrhea. In 2016, the WHO estimated that poor WASH practices were responsible for 829,000 deaths from diarrheal disease – equivalent to 1.9% of the global burden of disease. Cholera, an acute diarrheal disease linked to contaminated water that can kill within hours if left untreated, infects up to 4 million people each year, and kills an estimated 21,000-143,000 people. The spread of other diseases, like typhoid and measles, increase precipitously in the developing world when domestic water supply outages occur. In some individuals these diseases are fatal, and in many others their burden leads to reduced labor productivity and wages. Where the burden is high, repeated illnesses for family members can trap households in a vicious poverty cycle.  

The provision of safely managed WASH services.

Basic WASH services and medical waste management in health care facilities are essential for safe and quality care.  

Basic water supply, sanitation and hygiene services in schools are essential for safe and quality care.  

Strengthening multi-sector, national institutions and platforms for policy development and the coordination of prevention and preparedness, including for anti-microbial resistance.

Country Examples

The World Bank moves quickly to help countries respond to COVID-19. Below are some examples in the WASH sector:

• In the  Democratic Republic of Congo , we’re supporting a communications campaign to ensure that people across the DRC know about the importance of handwashing and physical distancing.
• Resources in  Ethiopia  have  been quickly mobilized to respond to the COVID-19 emergency.  Working with the Ministry of Health and the Addis Ababa Water and Sewerage Authority,  we’re working to ensure all healthcare facilities have around-the-clock access to water. In addition, water pumps and boreholes in Addis are being replaced and rehabilitated to provide services to those living in this dense urban area.
• A project in  Sri Lanka  will raise public awareness about handwashing and promote the importance of hygiene. The information will be accessible to all affected stakeholders, using different languages, addressing cultural sensitivities, and reaching those with illiteracy or disabilities.
• In  Haiti,  we’re focusing on immediate response measures including: purchasing chlorine to ensure that water is clean,  installing handwashing stations, soap and water supply in critical areas such as markets, health centers, orphanages, and prisons.  Our support in Haiti also includes the construction and rehabilitation of WASH infrastructure in COVID19 triage and treatment zones in hospitals and health centers. This is in addition to ensuring safe water and basic sanitation, including waste management disposal in healthcare facilities and quarantine shelters. Medium-term measures including ensuring that water utilities have the required financial and safe operational conditions to continue delivering services.

Safe water supply, sanitation and hygiene services and medical waste management in health care facilities

Steps Healthcare Facilities Can Take Now to Prepare for Coronavirus Disease 2019 (COVID-19) , CDC 

Coronavirus disease (COVID-19) technical guidance: Infection prevention and control / WASH , WHO 

Interim Guidance on Scaling-up COVID-19 Outbreak in Readiness and Response Operations in Camps and Camp-like Settings , jointly developed by IFRC, IOM, UNHCR and WHO 

WASH in Health Care Facilities: Global Baseline Report 2019 , WHO and UNICEF 

Water and sanitation for health facility improvement tool (WASH FIT) , WHO and UNICEF 

Emergency support to water and sanitation utilities

Business Continuity Planning for Water Utilities: Guidance Document (AWWA, USEPA, and WRF)

Water System Preparedness and Best Practices for Pandemic Influenza

AWWA Emergency Preparedness Practices

Emergency Planning for Water and Wastewater Utilities   

Stantec Whitepaper: Introduction to Coronavirus and Considerations for Water and Wastewater Treatment

WEF Water Professional’s Guide to COVID-19

CDC: Guidance for Reducing Health Risks to Workers Handling Human Waste or Sewerage   

Occupational Safety and Health Administration: COVID-19 Control and Prevention   

AWWA Guidance on Shutoffs and Return to Service : Given the importance of hygiene and sanitation in mitigating the spread of COVID-19, AWWA recommends utilities postpone water shutoffs during the COVID-19 pandemic. 

AWWA COVID-19 Resources

Water World Article on Immediate Actions to Improve Resilience

Providing technical assistance to governments to strengthen country systems

Make Way for the Future of Sanitation: A Review of New Enterprise Models Shaping the Development of a Transformational Sanitation Economy , The Toilet Board Coalition (TBC) and EY.   

COVID-19 response: Water Utility Preparation Guidelines , American Water Works Association (AWWA) 

Emergency Planning for Water and Wastewater Utilities , AWWA 

Drinking Water Utility Emergency Response Plan Template and Instructions , United States Environmental Protection Agency (EPA) 

Letter to utility chief executives on COVID-19 response , Ofwat (UK regulator) 

Resilience in the round: Building resilience for the future , Ofwat 

Water Professional's Guide to COVID-19 , Water Environment Federation (WEF) 

This work is partly supported by the  Global Water Security & Sanitation Partnership (GWSP) .

• New* COVID-19 Financial Impact Assessment Tool for Water and Sanitation Providers
• Multimedia package: As Haiti Braces for the COVID-19 Pandemic, Water, Sanitation, and Hygiene Are More Important Than Ever
• Multimedia Package: COVID-19 Makes Handwashing Facilities and Promotion More Critical Than Ever
• Blog: Handwashing with soap – a life-saving act
• Blog: Latin America moving fast to ensure water services during COVID-19
• Feature story: Tackling COVID-19 (Coronavirus) with Water, Sanitation and Hygiene in DRC
• Feature story: In Ethiopia, Keeping Water Flowing During the COVID-19 (Coronavirus) Response
• Blog: Examining the pandemic’s impact on the irrigation and drainage sector and opportunities for recovery
• Blog: Adapting in the pandemic to provide water and sanitation to Indonesia’s rural poor
• Feature Story: Preparing for the Unpredictable - Lessons for the COVID-19 Response from Bangladesh
• Blog: 10 steps to developing a communications strategy to help combat COVID-19 (Coronavirus)

World Health Organization

World Health Organization Coronavirus disease 2019

Water, sanitation, hygiene and waste management for COVID-19

Global Handwashing Partnership

Coronavirus outbreak

The World Bank

World Bank response to COVID-19

WSP.org archives on Sanitation and hygiene

WSP Sanitation marketing toolkit

Handwashing with soap toolkit

Sanitation and Water for All

COVID-19 and WASH

Handwashing with soap is the first line of defense against COVID-19

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• December 13, 2023

A Stream of Solutions: Highlights from the Annual Water, Sanitation, and Hygiene Symposium at the Blum Center

By Alisha Dalvi

In 2007, the Blum Center hosted UC Berkeley’s first Water, Sanitation, and Hygiene (WASH) symposium for scholars and development practitioners. The event was the first of its kind in the Bay Area, and for the next decade, Stanford and Berkeley hosted WASH events on alternating years. After a hiatus due the pandemic, the symposium was back this year for the first time since 2019. This time, it’s the Blum Center continuing the tradition, with a wider scope of research and a larger community since the original WASH event over 15 years ago. 

Water, sanitation, and hygiene are crucial pillars of public health initiatives and in the fight against poverty. Issues like inadequate water access and poor sanitation disproportionately affect under-resourced communities, leading to waterborne diseases and socioeconomic impacts within vulnerable populations. Solutions are interdisciplinary, blending research findings and policy interventions in pursuit of infrastructure development, with communities’ contexts and needs at the core of WASH efforts. Practitioners range from chemical and environmental engineers to public health professionals. 

On December 6, the Blum Center hosted graduate students, professors, and experts with one common connection — a commitment to sharing and expanding collective knowledge in the WASH sector. The event kicked off with an introduction from its head coordinators, Prof. Amy Pickering , Blum Center Distinguished Chair in Global Poverty and Practice, and Prof. Kara Nelson , Blum Chancellor’s Chair in Development Engineering. Icebreakers followed, where attendees broke out into teams to play a sanitation-inspired game. 

The main attractions, however, were six longer research presentations and 17 quicker lightning talks, which included research developments that have concluded, are currently underway, or still in planning stages. They covered biological, environmental, and social issues, from cost assessments of water supplies to chlorination techniques for reducing maternal and neonatal diseases to proposing a compostable toilet. 

The sheer scope of presentations demonstrated the multifaceted range of the field. “WASH challenges primarily affect low-resourced and underserved communities,” says Nelson. “Those in the field have to understand these problems from an interdisciplinary perspective.” 

The end of the night featured a reception and awards. Joyce Kisiangani , a UC Berkeley PhD student, won for Best Visuals for her presentation introducing a low-cost passive-chlorination device for disinfecting water at the point of collection. Another UC Berkeley PhD student, J’Anna-Mare Lue , won for Most Creative for her presentation on water as a medium to address environmental inequity. Christine Pu , a PhD candidate at Stanford, was awarded Most Engaging for her discussion of how investments in water infrastructure transform rural livelihoods in Ethiopia. 

The event was deliberately small and intimate, designed to cultivate in-depth conversations and small-group discussions. “It is an event by and for the people who participate in the WASH field,” Nelson says. Hannah Wharton , a environmental engineering PhD student in Pickering’s lab and a member of the WASH symposium student committee, agreed. “Connecting with other researchers and professionals in the WASH field is so important for making progress on the global inequities that we are all trying to eliminate,” she says. “Having people there from a variety of fields really speaks to the interdisciplinarity of WASH and the need for future events.”

With around 60 attendees and plenty of time for networking, WASH aficionados were able to dive deep into the complexities of their peers’ projects. “Compared to the scale of the problems, we are a relatively small group of researchers working on them,” says Nelson. “We have to be resourceful and work in teams. And have a strong community that is supportive and lifts you up when you are feeling discouraged.” 

When asked what they hoped to see in the future for WASH events, nearly every attendee had a similar answer: “To see more people!” They are certainly on track to meet this goal — each year, event planners have welcomed more and more first-time attendees. The increase in symposium attendance parallels new and expanding research projects in the field, like those of Kisiangani, Lue, and Pu. And as the WASH sector grows, these symposia are vital to encouraging collaboration and fostering a network where projects can succeed on an individual and community level. 

“Next year,” Wharton says, “we want to host even more members of the community and continue increasing dialogue.”

More Articles

Geographer Ross Doll Joins GPP Program

We are thrilled to welcome Dr. Doll as our new lecturer for GPP 115. This course serves students all across campus, introducing them to historical and contemporary debates on addressing poverty and inequality in the world. Dr. Doll’s extensive experience in the disciplines of critical development studies, political ecology, and cultural geography will bring a valuable perspective to this course.

“The Best of UC Berkeley”: GPP Minor Graduates Its 17th Class

Last month, the Global Poverty and Practice minor’s Class of 2024 celebrated a hard-earned and well-deserved commencement with an intimate ceremony in Sutardja Dai Hall’s Banatao Auditorium.

USAID Digital Workforce Development Program, Led by Blum Center at UC Berkeley, Wins Digital Development Award

USAID Digital Workforce Development program, which launched in 2022, has strengthened the information and technology (ICT) skills of Cambodian faculty, developed career centers at their universities, overseen skills training for students, and provided scholarships in the digital and ICT fields, particularly for rural, female students.

Blum Center Students and Faculty Take Up the Mantle of the International Decade of Sciences for Sustainable Development

Soliver Ché Fusi is an environmental engineering PhD candidate at UC Berkeley. She hurries online to speak with me late in the Kenyan evening about her work at the Blum Center for Developing Economies. She’s telling me how the technology she’s working on hits on all these target issues — and it’s simple: sustainable agricultural fertilizer.

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Effect of water treatment processes on microbial contamination in drinking water in rural areas of the urban periphery

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Lan Zhang , Can Zhao , Shenghua Cao , Bixiong Ye; Effect of water treatment processes on microbial contamination in drinking water in rural areas of the urban periphery. Journal of Water, Sanitation and Hygiene for Development 2024; washdev2024419. doi: https://doi.org/10.2166/washdev.2024.419

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The water treatment infrastructure facilities play an important role in ensuring the safety of drinking water. A survey of the drinking water treatment process was conducted in the urban peripheral areas of Beijing, China, and the main water treatment infrastructure facilities in terms of their impact on microbial contamination were investigated. The sedimentation equipment, filtration facilities, and disinfection equipment are all significantly correlated with the concentration of heterotrophic plate counts in drinking water. The filtration facilities and disinfection equipment were also positively correlated with the concentration of total coliform and Escherichia coli . The effect of removing microorganisms by different water disinfection methods gradually decreases in the order of ozone, chlorine, chlorine dioxide, and ultraviolet light. The effect of microbial contamination removal of different water pumping methods is as follows: direct water supply > pressure tank > secondary pressing pump station > water tower > high-level water tank, and the removal effects are 7.6, 7.4, 4.1, 3.6, and 1.7 times that of self-flowing water supply. The study provides scientific support for the renovation, and upgrading of microbial pollution reduction in drinking water in rural areas of the urban periphery.

The drinking water treatment process and the main water treatment infrastructure facilities regarding their influence on microbial contamination were investigated.

The effect of microbial contamination removal using diverse water disinfection methods was discussed.

The relationship between the different water pumping methods and microbial contamination was also explored.

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Webinar on Water and Sanitation Technology Options for Health-care Facilities, 2024 - Recommendations and conclusions

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During the UN 2023 Water Conference, the United Nations Secretary-General urged the global community to respect, protect and share water for the benefit of people and the planet. The conference highlighted the importance of recognizing water as a global common good, ensuring universal access to safe drinking-water and sanitation, and utilizing water as a catalyst for health and well-being, nutrition and energy. Numerous countries pledged increased investments in water infrastructure as well as improved access to safe water and sanitation services. The conference also emphasized the need for capacity-building, technology transfer, innovations to solve the water crisis and knowledge sharing.

In a resolution on water, sanitation and hygiene (WASH) in health-care facilities adopted at the Seventy-second World Health Assembly in 2019, global targets were established calling for at least 80% of all health-care facilities globally to have basic WASH services by 2025 and 100% by 2030. Considering this target, some Member States still require support to expedite progress towards these targets. Innovation in practice and technologies can serve as an accelerator, leading to improved water resources and sanitation development and management. By sharing and disseminating research and technologies, an enabling environment can be created for new and sustainable solutions that ensure full coverage of water and sanitation services. Focus should be placed on designing tailored solutions considering each location’s unique context, ranging from scaling up best practices, leveraging accessible and disruptive technologies relevant to the assessed scenario, to incorporating ecological and traditional approaches to accelerate progress and ensure that no one is left behind.

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Improving access to water, sanitation and hygiene can save 1.4 million lives per year, says new WHO report

Half of the world’s population still does not have adequate access to safe drinking water, sanitation and hygiene (WASH) which could have prevented at least 1.4 million deaths and 74 million disability-adjusted life years in 2019, according to the latest report by the World Health Organization (WHO) and an accompanying article published in The Lancet.

“With growing WASH-related health risks seen already today through conflicts, the emergence of antimicrobial resistance, the re-emergence of cholera hotspots, and the long-term threats from climate change, the imperative to invest is stronger than ever” said Dr Maria Neira, Director, WHO Department of Environment, Climate Change and Health. “ We have seen improvements in WASH service levels over the last 10 years, but progress is uneven and insufficient”

Burden of disease attributable to unsafe drinking water, sanitation, and hygiene: 2019 update presents estimates of the burden of disease attributable to unsafe drinking water, sanitation and hygiene for 183 WHO Member States disaggregated by region, age and sex for the year 2019. The estimates are based on four health outcomes - diarrhoea, acute respiratory infections, undernutrition, and soil-transmitted helminthiases. 

Diarrhoeal disease accounted for most of the attributable burden, with over one million deaths and 55 million DALYs.  The second largest contributor was acute respiratory infections from inadequate hand hygiene, which was linked to 356 000 deaths and 17 million DALYs.

Among children under five, unsafe WASH was responsible for 395 000 deaths and 37 million DALYs, representing 7.6% of all deaths and 7.5% of all DALYs in this age group. This included 273 000 deaths from diarrhoea and 112 000 deaths from acute respiratory infections. These diseases are the top two infectious causes of death for children under five globally.

Important disparities were noted between regions and income groups. More than three-quarters of all WASH-attributable deaths occurred in the WHO African and South-East Asia regions, while 89% of attributable deaths were from low- and lower-middle income countries. However, even high-income countries are at risk, as 18% of their diarrhoeal disease burden could be prevented through improved hand hygiene practices.

While these estimates included four health outcomes for which data were available to quantify the impact, the true burden is likely to be much higher. The impacts of unsafe WASH on health are wide-ranging and go beyond disease by affecting social and mental well-being. In addition, climate change is likely to exacerbate many WASH-related diseases and risks which are not fully captured in the present estimates.

To reduce the WASH-attributable burden of disease, WHO urges governments to take the following actions with support from UN agencies, multilateral partners, the private sector and civil society organizations: 

• Radically accelerate action to make safe WASH a reality for all. The mid-term comprehensive review of the International Decade for Action Towards the Sustainable Development Goals saw renewed commitments from governments to accelerate progress towards the goal of universal access to safe WASH. By quantifying for the first time the health gains associated with higher WASH service levels, the updated estimates provide strong evidence to support efforts to take these commitments to action.
• Focus efforts on the poorest and most disadvantaged. The burden of disease is largely driven by inadequate access in low- and middle- income countries, and national estimates on WASH access often hide disparities within countries. Access to WASH services is typically lower among rural populations and lower socio-economic groups. Even in high-income countries, where access to safely managed drinking-water and sanitation services is generally high, certain marginalized communities are underserved and face higher risks.
• Adapt national monitoring systems to improve data on population exposure to safely managed services. Data on higher levels of WASH services remain sparse in many countries. Governments should adapt national and local monitoring systems taking into consideration the higher service levels called for in the SDG framework, enabling a more accurate reflection of the full burden of disease associated with unsafe WASH.

“It is clear that inadequate access to safe water, sanitation, and hygiene services continues to pose a significant, and preventable, health risk, particularly to the most vulnerable populations,” said Mr. Bruce Gordon, Head, WHO Water, Sanitation, Hygiene and Health Unit. “The health benefits, as quantified in the report, are immense. Prioritizing those most in need is not just a moral imperative; it is key to addressing the disproportionate disease burden in low and middle-income countries and among marginalized groups in high-income countries.”

To support governments, WHO also today released a new tool to model disease impacts from different WASH scenarios. The tool will foster informed policy-making, guide targeted interventions, and support strategic resource allocation for WASH programming.

Note to editors:

The burden of disease associated with unsafe WASH is still substantial. This analysis estimates the WASH-attributable burden of disease that can be prevented by meeting SDG targets 6.1 and 6.2.  While comprehensive data on the SDG indicators used to track these targets still have important limitations , our estimates demonstrate the added value of collecting information on these service levels in order to reflect more fully the burden of disease associated with unsafe WASH.

Related links:

Access the report here and the Lancet article here

Access key data here

Access the country analytical tool here

Dedicated to the well-being of all people and guided by science, the World Health Organization leads and champions global efforts to give everyone, everywhere an equal chance at a safe and healthy life. We are the UN agency for health that connects nations, partners and people on the front lines in 150+ locations – leading the world’s response to health emergencies, preventing disease, addressing the root causes of health issues and expanding access to medicines and health care. Our mission is to promote health, keep the world safe and serve the vulnerable. www.who.int   

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Lot quality assurance sampling survey for water, sanitation and hygiene monitoring and evidence-based advocacy in Bentiu IDP camp, South Sudan

• Tesfay, Berhe Etsay
• Gobezie, Destaw
• Sinaga, Ivan Andreas
• Jacob, Amanya
• Mullahzada, Abdul Wasay
• Hussain, Samreen
• de Boer, Rosita
• Pop-stefanija, Biserka
• Slosarska, Monika
• Keating, Patrick

Background Every year, 60% of deaths from diarrhoeal disease occur in low and middle-income countries due to inadequate water, sanitation, and hygiene. In these countries, diarrhoeal diseases are the second leading cause of death in children under five, excluding neonatal deaths. The approximately 100,000 people residing in the Bentiu Internally Displaced Population (IDP) camp in South Sudan have previously experienced water, sanitation, and hygiene outbreaks, including an ongoing Hepatitis E outbreak in 2021. This study aimed to assess the gaps in Water, Sanitation, and Hygiene (WASH), prioritise areas for intervention, and advocate for the improvement of WASH services based on the findings. Methods A cross-sectional lot quality assurance sampling (LQAS) survey was conducted in ninety-five households to collect data on water, sanitation, and hygiene (WASH) coverage performance across five sectors. Nineteen households were allocated to each sector, referred to as supervision areas in LQAS surveys. Probability proportional to size sampling was used to determine the number of households to sample in each sector block selected using a geographic positioning system. One adult respondent, familiar with the household, was chosen to answer WASH-related questions, and one child under the age of five was selected through a lottery method to assess the prevalence of WASH-related disease morbidities in the previous two weeks. The data were collected using the KoBoCollect mobile application. Data analysis was conducted using R statistical software and a generic LQAS Excel analyser. Crude values, weighted averages, and 95% confidence intervals were calculated for each indicator. Target coverage benchmarks set by program managers and WASH guidelines were used to classify the performance of each indicator. Results The LQAS survey revealed that five out of 13 clean water supply indicators, eight out of 10 hygiene and sanitation indicators, and two out of four health indicators did not meet the target coverage. Regarding the clean water supply indicators, 68.9% (95% CI 60.8%-77.1%) of households reported having water available six days a week, while 37% (95% CI 27%-46%) had water containers in adequate condition. For the hygiene and sanitation indicators, 17.9% (95% CI 10.9%-24.8%) of households had handwashing points in their living area, 66.8% (95% CI 49%-84.6%) had their own jug for cleansing after defaecation, and 26.4% (95% CI 17.4%-35.3%) of households had one piece of soap. More than 40% of households wash dead bodies at funerals and wash their hands in a shared bowl. Households with sanitary facilities at an acceptable level were 22.8% (95% CI 15.6%-30.1%), while 13.2% (95% CI 6.6%-19.9%) of households had functioning handwashing points at the latrines. Over the previous two weeks, 57.9% (95% CI 49.6–69.7%) of households reported no diarrhoea, and 71.3% (95% CI 62.1%-80.6%) reported no eye infections among children under five. Conclusion The camp's hygiene and sanitation situation necessitated immediate intervention to halt the hepatitis E outbreak and prevent further WASH-related outbreaks and health issues. The LQAS findings were employed to advocate for interventions addressing the WASH gaps, resulting in WASH and health actors stepping in.